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USMLE Step 2

Clinical Knowledge (CK)


Sample Test Questions
A Joint Program of the Federation of State Medical Boards of the United States, Inc.,
and the National Board of Medical Examiners

This booklet updated July 2014.


Copyright 2014 by the Federation of State Medical Boards of the United States, Inc. (FSMB), and the
National Board of Medical Examiners (NBME). All rights reserved. Printed in the United States of
America. The United States Medical Licensing Examination (USMLE) is a joint program of the FSMB and
the NBME.

CONTENTS

USMLE Step 2 CK Test Question Formats 3


Introduction to USMLE Step 2 CK Sample Test Questions . 6
Normal Laboratory Values ...... 7
USMLE Step 2 CK Sample Test Questions.... 9
Answer Form for USMLE Step 2 CK Sample Test Questions 53
Answer Key for USMLE Step 2 CK Sample Test Questions. 54

USMLE Step 2 CK Test Question Formats


Single-Item Questions
This is the traditional, most frequently used multiple-choice format. It consists of a vignette and question followed by
three to twenty-six options that are in alphabetical or logical order. The response options in this format are lettered (eg, A,
B, C, D, E). You are required to select the one best answer to the question. Other options may be partially correct, but
there is only ONE BEST answer.
Items with an associated pharmaceutical ad or abstract were introduced into the examination in August 2011. Each
pharmaceutical ad or abstract appears as a 2- or 3-item set; there are no more than 5 of these item sets in each
examination. Because item sets with an associated pharmaceutical ad or abstract may require more time to answer than
traditional multiple-choice items, blocks that include a pharmaceutical ad or abstract item set contain fewer items.
Strategies for Answering Single One-Best-Answer Test Questions
The following are strategies for answering one-best-answer items:

Read each question carefully. It is important to understand what is being asked.

Try to generate an answer and then look for it in the response option list.

Alternatively, read each response option carefully, eliminating those that are clearly incorrect.

Of the remaining response options, select the one that is most correct.

If unsure about an answer, it is better to guess since unanswered questions are automatically counted as wrong
answers.

Example Item 1: Single-Item Question


A 32-year-old woman with type 1 diabetes mellitus has had progressive renal failure over the past 2 years. She has not yet
started dialysis. Examination shows no abnormalities. Her hemoglobin concentration is 9 g/dL, hematocrit is 28%, and
mean corpuscular volume is 94 m3. A blood smear shows normochromic, normocytic cells. Which of the following is the
most likely cause?
(A)
(B)
(C)
(D)
(E)
(F)

Acute blood loss


Chronic lymphocytic leukemia
Erythrocyte enzyme deficiency
Erythropoietin deficiency
Immunohemolysis
Microangiopathic hemolysis

(G)
(H)
(I)
(J)

(Answer: D)

Polycythemia vera
Sickle cell disease
Sideroblastic anemia
-Thalassemia trait

Sequential Item Sets


A single patient-centered vignette may be associated with two or three consecutive questions about the information
presented. Each question is associated with the initial patient vignette but is testing a different point. You are required to
select the ONE BEST answer to each question. These questions are designed to be answered in sequential order. You
must click Proceed to Next Item to view the next item in the set; once you click on this button, the next question will be
displayed, and you will not be able to return to the previous question or change the answer to it.

Matching Item Sets


This format consists of a series of questions related to a common topic. All matching sets contain set-specific
instructions, a list of lettered response options, and at least two questions. There will be between four and twentysix response options. Each set is preceded by a box that indicates the number of questions in the set associated
with the response options that follow. You will be directed to select one answer for each question in the set.
Questions will be presented one at a time, with instructions and response options repeated for each subsequent
question.

Strategies for Answering Matching Item Sets

Begin each set by reading through the response options to become familiar with the available choices.

Read each question carefully.

Within a set, some response options may be used several times as the answer to more than one question, while
other options may not be used as answers at all. Respond to each question independently.

For matching sets with large numbers of response options, try to generate an answer to the question and then
locate the answer in the response option list. This is more efficient than considering each response option
individually.

Example Items 2-3: Matching Set


The response options for the next 2 items are the same. Select one answer for each item in the set.

(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(I)
(J)

Chronic lymphocytic leukemia


Drug reaction
Hodgkin disease
Infectious mononucleosis
Metastatic carcinoma
Sarcoidosis
Systemic lupus erythematosus
Toxoplasmosis
Tuberculosis
Tularemia

For each patient with lymphadenopathy, select the most likely diagnosis.
2. A previously healthy 30-year-old man has had fever, night sweats, pruritus, and an enlarging lump above his left
clavicle for 3 weeks. Examination shows a 3-cm, nontender, rubbery, supraclavicular lymph node. An x-ray of the
chest shows mediastinal lymphadenopathy.
(Answer: C)
3. A 41-year-old woman comes to the physician for a follow-up examination. She has taken aspirin for chronic
headaches and phenytoin for a seizure disorder for 2 years. Examination shows mild epigastric tenderness and
bilateral, 3-cm, nontender axillary lymph nodes. A lymph node biopsy shows hyperplasia.
(Answer: B)

NOTE: When additional item formats are added to the examination, notice will be provided on the USMLE Web site
(http://www.usmle.org). You must monitor the Web site to stay informed about the types of items that occur in the
examination, and you must practice with the downloadable sample test items available on the USMLE Web site in order
to be fully prepared for the examination.

Introduction to USMLE Step 2 CK Sample Test Questions


The following pages include 131 sample test questions. Most of these questions are the same as those you can install on
your computer from the USMLE Web site. Please note that reviewing the sample questions as they appear on pages 9-52
is not a substitute for practicing with the test software. You should download and run the Step 2 CK examination tutorial
and practice test items that are provided on the USMLE Web site well before your test date. The sample materials
available on the USMLE Web site include additional items and item formats that do not appear in this booklet, such as
pharmaceutical ad and abstract item sets, items with associated audio or video findings, and sequential item sets. You
should become familiar with all item formats that will be used in the actual examination.
Although the sample questions exemplify content on the examination, they may not reflect the content coverage on
individual examinations. In the actual examination, questions will be presented in random order. The questions will be
presented one at a time in a format designed for easy on-screen reading, including the use of exhibit buttons for some
pictorials and a Normal Laboratory Values button (Table included here on pages 78). Photographs, charts, and x-rays in
this booklet are not of the same quality as the pictorials used in the actual examination. In addition, you will be able to
adjust the brightness and contrast of the computer screen.
To take the following sample test questions as they would be timed in the actual examination, you should allow a
maximum of one hour for each block, for a total of three hours. Please be aware that most examinees perceive the time
pressure to be greater during an actual examination. An answer form for recording answers is provided on page 53. An
answer key is provided on page 54. In the actual examination, answers will be selected on the screen; no answer form will
be provided.

LABORATORY VALUES
* Included in the Biochemical Profile (SMA-12)
REFERENCE RANGE
SI REFERENCE INTERVALS
BLOOD, PLASMA, SERUM
* Alanine aminotransferase (ALT), serum................. 8-20 U/L ....................................................8-20 U/L
Amylase, serum ...................................................... 25-125 U/L.................................................25-125 U/L
* Aspartate aminotransferase (AST), serum .............. 8-20 U/L .....................................................8-20 U/L
Bilirubin, serum (adult) Total // Direct ................... 0.1-1.0 mg/dL // 0.0-0.3 mg/dL ................2-17 mol/L // 0-5 mol/L
* Calcium, serum (Ca2+) ............................................ 8.4-10.2 mg/dL ..........................................2.1-2.8 mmol/L
* Cholesterol, serum .................................................. Rec:<200 mg/dL .......................................<5.2 mmol/L
Cortisol, serum ........................................................ 0800 h: 5-23 g/dL // 1600 h: 3-15 g/dL 138-635 nmol/L // 82-413 nmol/L
2000 h: < 50% of 0800 h............................Fraction of 0800 h: < 0.50
Creatine kinase, serum ............................................ Male: 25-90 U/L .......................................25-90 U/L
Female: 10-70 U/L ....................................10-70 U/L
* Creatinine, serum .................................................... 0.6-1.2 mg/dL ...........................................53-106 mol/L
Electrolytes, serum
Sodium (Na+) ........................................................ 136-145 mEq/L ..........................................136-145 mmol/L
* Potassium (K+) ...................................................... 3.5-5.0 mEq/L ............................................3.5-5.0 mmol/L
Chloride (Cl) ........................................................ 95-105 mEq/L ...........................................95-105 mmol/L
Bicarbonate (HCO3)............................................. 22-28 mEq/L .............................................22-28 mmol/L
Magnesium (Mg2+) ................................................ 1.5-2.0 mEq/L ............................................0.75-1.0 mmol/L
Estriol, total, serum (in pregnancy)
24-28 wks // 32-36 wks ......................................... 30-170 ng/mL // 60-280 ng/mL ................104-590 nmol/L // 208-970 nmol/L
28-32 wks // 36-40 wks ......................................... 40-220 ng/mL // 80-350 ng/mL ................140-760 nmol/L // 280-1210 nmol/L
Ferritin, serum ......................................................... Male: 15-200 ng/mL .................................15-200 g/L
Female: 12-150 ng/mL ..............................12-150 g/L
Follicle-stimulating hormone, serum/plasma ......... Male: 4-25 mIU/mL ..................................4-25 U/L
Female: premenopause 4-30 mIU/mL ......4-30 U/L
midcycle peak 10-90 mIU/mL ...............10-90 U/L
postmenopause 40-250 mIU/mL ............40-250 U/L
Gases, arterial blood (room air)
pH ........................................................................ 7.35-7.45 ...................................................[H+] 36-44 nmol/L
PCO2 ..................................................................... 33-45 mm Hg .............................................4.4-5.9 kPa
PO2 ....................................................................... 75-105 mm Hg ...........................................10.0-14.0 kPa
* Glucose, serum........................................................ Fasting: 70-110 mg/dL ..............................3.8-6.1 mmol/L
2-h postprandial: < 120 mg/dL .................< 6.6 mmol/L
Growth hormone - arginine stimulation .................. Fasting: < 5 ng/mL ....................................< 5 g/L
provocative stimuli: > 7 ng/mL ..............> 7 g/L
Immunoglobulins, serum
IgA ....................................................................... 76-390 mg/dL ............................................0.76-3.90 g/L
IgE ........................................................................ 0-380 IU/mL .............................................0-380 kIU/L
IgG ....................................................................... 650-1500 mg/dL ........................................6.5-15 g/L
IgM ...................................................................... 40-345 mg/dL ...........................................0.4-3.45 g/L
Iron ......................................................................... 50-170 g/dL ............................................9-30 mol/L
Lactate dehydrogenase, serum ................................ 45-90 U/L ...................................................45-90 U/L
Luteinizing hormone, serum/plasma ...................... Male: 6-23 mIU/mL ..................................6-23 U/L
Female: follicular phase 5-30 mIU/mL .....5-30 U/L
midcycle 75-150 mIU/mL .......................75-150 U/L
postmenopause 30-200 mIU/mL ............30-200 U/L
Osmolality, serum ................................................... 275-295 mOsmol/kg H2O ..........................275-295 mOsmol/kg H2O
Parathyroid hormone, serum, N-terminal ............... 230-630 pg/mL .........................................230-630 ng/L
* Phosphatase (alkaline), serum (p-NPP at 30C) ..... 20-70 U/L ..................................................20-70 U/L
* Phosphorus (inorganic), serum ............................... 3.0-4.5 mg/dL ...........................................1.0-1.5 mmol/L
Prolactin, serum (hPRL) ........................................ < 20 ng/mL ................................................< 20 g/L
* Proteins, serum
Total (recumbent) ................................................. 6.0-7.8 g/dL ...............................................60-78 g/L
Albumin ................................................................ 3.5-5.5 g/dL................................................35-55 g/L
Globulin ............................................................... 2.3-3.5 g/dL................................................23-35 g/L
Thyroid-stimulating hormone, serum or plasma ..... 0.5-5.0 U/mL ..........................................0.5-5.0 mU/L
Thyroidal iodine (123I) uptake .................................. 8%-30% of administered dose/24 h ...........0.08-0.30/24 h
Thyroxine (T4), serum ............................................. 5-12 g/dL ................................................64-155 nmol/L
Triglycerides, serum ............................................... 35-160 mg/dL ............................................0.4-1.81 mmol/L
Triiodothyronine (T3), serum (RIA) ....................... 115-190 ng/dL ...........................................1.8-2.9 nmol/L
Triiodothyronine (T3) resin uptake.......................... 25%-35% ..................................................0.25-0.35
* Urea nitrogen, serum .............................................. 7-18 mg/dL ...............................................1.2-3.0 mmol/L
* Uric acid, serum ...................................................... 3.0-8.2 mg/dL ...........................................0.18-0.48 mmol/L
7

LABORATORY VALUES (continued from previous page)


REFERENCE RANGE
SI REFERENCE INTERVALS
BODY MASS INDEX (BMI)
Body mass index .......................................................Adult: 19-25 kg/m2
CEREBROSPINAL FLUID
Cell count ..................................................................0-5/mm3 .............................................................0-5 x 106/L
Chloride ...................................................................118-132 mEq/L .................................................118-132 mmol/L
Gamma globulin .......................................................3%-12% total proteins .......................................0.03-0.12
Glucose ....................................................................40-70 mg/dL .....................................................2.2-3.9 mmol/L
Pressure ....................................................................70-180 mm H2O ...............................................70-180 mm H2O
Proteins, total ...........................................................<40 mg/dL .......................................................<0.40 g/L
HEMATOLOGIC
Bleeding time (template) ..........................................2-7 minutes ........................................................2-7 minutes
Erythrocyte count ......................................................Male: 4.3-5.9 million/mm3 ................................4.3-5.9 x 1012/L
Female: 3.5-5.5 million/mm3 ............................3.5-5.5 x 1012/L
Erythrocyte sedimentation rate (Westergren) ...........Male: 0-15 mm/h ..............................................0-15 mm/h
Female: 0-20 mm/h ...........................................0-20 mm/h
Hematocrit ...............................................................Male: 41%-53% ...............................................0.41-0.53
Female: 36%-46% .............................................0.36-0.46
Hemoglobin A1c ........................................................< 6% ..................................................................< 0.06
Hemoglobin, blood ...................................................Male: 13.5-17.5 g/dL ........................................2.09-2.71 mmol/L
Female: 12.0-16.0 g/dL .....................................1.86-2.48 mmol/L
Hemoglobin, plasma .................................................1-4 mg/dL ..........................................................0.16-0.62 mmol/L
Leukocyte count and differential
Leukocyte count ......................................................4500-11,000/mm3 ..............................................4.5-11.0 x 109/L
Segmented neutrophils ..........................................54%-62% ..........................................................0.54-0.62
Bands ....................................................................3%-5% ..............................................................0.03-0.05
Eosinophils ...........................................................1%-3% ..............................................................0.01-0.03
Basophils ...............................................................0%-0.75% ..........................................................0-0.0075
Lymphocytes ........................................................25%-33% ...........................................................0.25-0.33
Monocytes ............................................................3%-7% ..............................................................0.03-0.07
Mean corpuscular hemoglobin ..................................25.4-34.6 pg/cell ...............................................0.39-0.54 fmol/cell
Mean corpuscular hemoglobin concentration ..........31%-36% Hb/cell .............................................4.81-5.58 mmol Hb/L
Mean corpuscular volume ........................................80-100 m3 ........................................................80-100 fL
Partial thromboplastin time (activated) ....................25-40 seconds ....................................................25-40 seconds
Platelet count.............................................................150,000-400,000/mm3 .......................................150-400 x 109/L
Prothrombin time ......................................................11-15 seconds ....................................................11-15 seconds
Reticulocyte count ....................................................0.5%-1.5% .........................................................0.005-0.015
Thrombin time ..........................................................<2 seconds deviation from control ...................<2 seconds deviation from
control
Volume
Plasma ....................................................................Male: 25-43 mL/kg ...........................................0.025-0.043 L/kg
Female: 28-45 mL/kg ........................................0.028-0.045 L/kg
Red cell ...................................................................Male: 20-36 mL/kg ..........................................0.020-0.036 L/kg
Female: 19-31 mL/kg .......................................0.019-0.031 L/kg
SWEAT
Chloride ....................................................................0-35 mmol/L ....................................................0-35 mmol/L
URINE
Calcium ....................................................................100-300 mg/24 h ...............................................2.5-7.5 mmol/24 h
Chloride ....................................................................Varies with intake .............................................Varies with intake
Creatinine clearance ..................................................Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)
30 wks .....................................................................6-18 mg/24 h .....................................................21-62 mol/24 h
35 wks .....................................................................9-28 mg/24 h .....................................................31-97 mol/24 h
40 wks .....................................................................13-42 mg/24 h ...................................................45-146 mol/24 h
17-Hydroxycorticosteroids .......................................Male: 3.0-10.0 mg/24 h .....................................8.2-27.6 mol/24 h
Female: 2.0-8.0 mg/24 h ...................................5.5-22.0 mol/24 h
17-Ketosteroids, total ................................................Male: 8-20 mg/24 h ...........................................28-70 mol/24 h
Female: 6-15 mg/24 h .......................................21-52 mol/24 h
Osmolality ................................................................50-1400 mOsmol/kg H2O
Oxalate ......................................................................8-40 g/mL .......................................................90-445 mol/L
Potassium .................................................................Varies with diet .................................................Varies with diet
Proteins, total ...........................................................<150 mg/24 h ...................................................<0.15 g/24 h
Sodium .....................................................................Varies with diet .................................................Varies with diet
Uric acid....................................................................Varies with diet .................................................Varies with diet
8

Sample Questions
Block 1 (Questions 1-41)

1.

A previously healthy 34-year-old woman is brought to the physician because of fever and headache for 1 week. She
has not been exposed to any disease. She takes no medications. Her temperature is 39.3C (102.8F), pulse is
104/min, respirations are 24/min, and blood pressure is 135/88 mm Hg. She is confused and oriented only to person.
Examination shows jaundice of the skin and conjunctivae. There are a few scattered petechiae over the trunk and
back. There is no lymphadenopathy. Physical and neurologic examinations show no other abnormalities. Test of the
stool for occult blood is positive. Laboratory studies show:
Hematocrit
Leukocyte count
Platelet count
Prothrombin time
Partial thromboplastin time
Fibrin split products
Serum
Urea nitrogen
Creatinine
Bilirubin
Total
Direct
Lactate dehydrogenase

32% with fragmented and nucleated erythrocytes


12,500/mm3
20,000/mm3
10 sec
30 sec
negative
35 mg/dL
3.0 mg/dL
3.0 mg/dL
0.5 mg/dL
1000 U/L

Blood and urine cultures are negative. A CT scan of the head shows no abnormalities. Which of the following is the
most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)

2.

Disseminated intravascular coagulation


Immune thrombocytopenic purpura
Meningococcal meningitis
Sarcoidosis
Systemic lupus erythematosus
Thrombotic thrombocytopenic purpura

A 27-year-old woman, gravida 3, para 2, at 25 weeks' gestation is admitted to the hospital 30 minutes after
spontaneous rupture of membranes. She reports that after walking a 5-km course 24 hours ago, she began to have
muscle aches and chills. Her temperature prior to going to bed last night was 38.9C (102F). She took 800 mg of
ibuprofen and awoke 8 hours later with severe abdominal pain and shaking chills. She began to vomit, then noted a
gush of blood-tinged fluid from her vagina. Her pregnancy had been uncomplicated. On admission, she appears ill.
Her temperature is 39.1C (102.3F), pulse is 110/min, respirations are 18/min, and blood pressure is 110/60 mm
Hg. Abdominal examination shows severe, diffuse tenderness throughout the lower quadrants. Pelvic examination
shows exquisite cervical motion and uterine tenderness. Speculum examination confirms rupture of membranes.
Ultrasonography shows the fetus in a vertex presentation. There is anhydramnios. Which of the following is the
greatest predisposing factor for this patient's premature rupture of membranes?
(A)
(B)
(C)
(D)
(E)

Emesis
Exercise
Ibuprofen use
Intra-amniotic infection
Multiparity

3.

A 72-year-old woman is brought to the emergency department 2 hours after the sudden onset of visual loss in her
right eye. Visual acuity is limited to light perception on the right. Examination of the right eye shows an afferent
papillary defect. The anterior structures of both eyes appear normal. Funduscopic findings of the right eye are
shown. Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)

4.

Age-related macular degeneration


Background diabetic retinopathy
Central artery occlusion
Central vein occlusion
Proliferative diabetic retinopathy

A 27-year-old man comes to the physician for a routine health maintenance examination. He says he feels well and
has not had any problems. He has no history of serious illness. He occasionally takes acetaminophen for headaches.
His brother had kidney failure at the age of 32 years. There is no family history of liver disease. The patient does not
smoke. He occasionally drinks a beer or a glass of wine. He has never used intravenous illicit drugs. He has had 10
lifetime male sexual partners and uses condoms consistently. He has been in a monogamous relationship for the past
3 years. His temperature is 37C (98.6F), pulse is 72/min, and blood pressure is 118/70 mm Hg. Examination
shows no abnormalities except for mild scleral icterus. Laboratory studies show:
Hematocrit
Leukocyte count
Prothrombin time
Serum
Na+
K+
Cl
HCO3
Urea nitrogen
Creatinine
Bilirubin, total
Direct
AST
ALT

44%
5000/mm3
11 sec (INR=1)
141 mEq/L
4.2 mEq/L
104 mEq/L
24 mEq/L
14 mg/dL
0.8 mg/dL
3.0 mg/dL
0.2 mg/dL
14 U/L
15 U/L

Serologic testing for hepatitis A and B is negative. Abdominal ultrasonography shows no abnormalities. Which of
the following is the most likely cause of these findings?
(A)
(B)
(C)
(D)
(E)

Decreased conjugation of bilirubin


Decreased excretion of bilirubin by hepatocytes
Decreased intracellular storage of bilirubin
Delayed uptake of bilirubin
Hemolysis

10

5.

A 37-year-old woman is brought to the emergency department because of intermittent chest pain for 3 days. The
pain is worse with inspiration, and she feels she cannot take deep breaths. She has not had shortness of breath,
palpitations, or nausea. She had an upper respiratory tract infection 10 days ago and took an over-the-counter cough
suppressant and decongestant and acetaminophen. Her temperature is 37.2C (98.9F), pulse is 90/min, and blood
pressure is 122/70 mm Hg. The lungs are clear to auscultation. S1 and S2 are normal. A rub is heard during systole.
There is no peripheral edema. An ECG shows normal sinus rhythm and diffuse, upwardly concave ST-segment
elevation and PR-segment depression in leads II, III, and aVF. Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)
(G)

6.

Acute pericarditis
Aortic dissection
Gastroesophageal reflux disease
Myocardial infarction
Peptic ulcer disease
Pulmonary embolism
Unstable angina pectoris

A previously healthy 42-year-old man is brought to the emergency department 1 day after the sudden onset of
shortness of breath and chest pain at rest; the pain is exacerbated by deep inspiration. His pulse is 100/min,
respirations are 22/min, and blood pressure is 140/90 mm Hg. Breath sounds are normal. The remainder of the
examination shows no abnormalities. Arterial blood gas analysis on room air shows:
pH
PCO2
PO2
O2 saturation

7.49
30 mm Hg
64 mm Hg
91%

An x-ray of the chest shows no abnormalities. Which of the following is the most likely mechanism of these
findings?
(A)
(B)
(C)
(D)
(E)
(F)
(G)

7.

Carbon monoxide poisoning


Congenital heart disease
Depressed alveolar ventilation
Interstitial edema
Interstitial fibrosis
Low oxygen-carrying capacity of the blood
Ventilation-perfusion mismatch

Six hours after delivery, a 1200-g (2-lb 11-oz) newborn develops respiratory distress. She was born at 32 weeks'
gestation. Her pulse is 136/min, respirations are 60/min, and blood pressure is 60/30 mm Hg. Examination shows
grunting and moderate intercostal and subcostal retractions. The lungs are clear to auscultation. Umbilical artery
blood gas analysis on 60% oxygen shows:
pH
PCO2
PO2

7.32
32 mm Hg
60 mm Hg

An x-ray of the chest shows diffuse reticulogranular densities with an air bronchogram. Which of the following is
the most likely underlying mechanism?
(A)
(B)
(C)
(D)
(E)
(F)

Abnormality of mucociliary function


Aspiration of meconium into the lungs
Blockage of airways with mucus
Increased pulmonary capillary permeability
Infection with group B streptococcus
Pulmonary surfactant deficiency

11

8.

A previously healthy 27-year-old nulligravid woman comes to the emergency department because of a 2-day history
of moderate-to-severe pain and swelling of the left labia. She is sexually active and uses condoms inconsistently.
Her temperature is 37.2C (99F), pulse is 92/min, respirations are 18/min, and blood pressure is 115/75 mm Hg.
Pelvic examination shows a 4 x 3-cm, tender, fluctuant mass medial to the left labium majus compromising the
introital opening. Which of the following is the most appropriate next step in management?
(A)
(B)
(C)
(D)
(E)

9.

A 4-year-old boy is brought for a follow-up examination. He has a history of chronic recurrent otitis media and
recently completed a 10-day course of antibiotics. His vital signs are within normal limits. Examination shows clear
ear canals and intact tympanic membranes; a brown, irregular mass is visualized behind the tympanic membrane.
Which of the following is the most likely explanation for these findings?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)

10.

Epithelial tissue proliferation


Lingual papillae loss
Middle ear effusion
Midface hypoplasia
Nerve entrapment
Olfactory hair cell degeneration
Semicircular canal edema
Tympanic membrane rupture

A 2-week-old newborn is brought to the physician because his lips have turned blue on three occasions during
feeding; he also sweats during feeding. He was born at 38 weeks' gestation and weighed 2466 g (5 lb 7 oz); he
currently weighs 2778 g (6 lb 2 oz). His temperature is 37.8C (100F), pulse is 170/min, respirations are 44/min,
and blood pressure is 75/45 mm Hg. A grade 3/6 harsh systolic ejection murmur is heard at the left upper sternal
border. An x-ray of the chest shows a small boot-shaped heart and decreased pulmonary vascular markings. Which
of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)

11.

Administration of intravenous metronidazole


Administration of intravenous penicillin G
Ultrasound-guided needle aspiration of the mass
Incision and drainage
Vulvectomy

Anomalous coronary vessels


Atrial septal defect
Endocardial fibroelastosis
Tetralogy of Fallot
Total anomalous pulmonary venous return

A 36-year-old nulligravid woman with primary infertility comes for a follow-up examination. She has been unable
to conceive for 10 years; analysis of her husband's semen during this period has shown normal sperm counts.
Menses occur at regular 28-day intervals and last 5 to 6 days. She is asymptomatic except for severe dysmenorrhea.
An endometrial biopsy specimen 5 days before menses shows secretory endometrium. Hysterosalpingography 1
year ago showed normal findings. Pelvic examination shows a normal vagina and cervix. Bimanual examination
shows a normal-sized uterus and no palpable adnexal masses. Rectal examination is unremarkable. Which of the
following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)

Anovulation
Endometriosis
Intrauterine synechiae
Male factor
Tubal obstruction

12

12.

A 65-year-old man who is quadriplegic as a result of multiple sclerosis is hospitalized for treatment of left lower
lobe pneumonia. His temperature is 38.1C (100.5F), pulse is 95/min, respirations are 12/min, and blood pressure is
120/80 mm Hg. He appears malnourished. Rhonchi are heard at the left lower lobe of the lung on auscultation.
Examination of the heart, lymph nodes, abdomen, and extremities shows no abnormalities. There is a 1-cm area of
erythema over the sacrum with intact skin and no induration. Neurologic examination shows quadriparesis. Test of
the stool for occult blood is negative. Which of the following is the most effective intervention for this patient's skin
lesion?
(A)
(B)
(C)
(D)
(E)

13.

A 22-year-old man with a seizure disorder has had increasing cough and shortness of breath for 3 days and fever for
1 day. He has foul-smelling sputum. He had a generalized tonic-clonic seizure 1 week ago. His temperature is
39.4C (103F). Crackles are heard on auscultation of the chest. An x-ray of the chest shows a right upper-lobe
infiltrate of the lung. Which of the following is the most likely cause?
(A)
(B)
(C)
(D)
(E)

14.

Chemical pneumonitis
Pneumonia secondary to anaerobes
Pneumonia secondary to gram-negative aerobes
Pneumonia secondary to gram-positive aerobes
Pneumonia secondary to Mycoplasma pneumoniae

A 37-year-old man with type 1 diabetes mellitus is admitted to the hospital because of inadequate control of his
glucose concentrations for the past 2 months. Despite his poor control, he demands that he be discharged. He reports
that he has had a 3-month history of fatigue, irritability, and feelings of hopelessness. He says that he has been
noncompliant with his diabetic regimen, adding, "Sometimes I forget." He has been avoiding his family and friends
because he is not in the mood to see them but admits that he is lonely. He did not get out of bed for 2 days, which
prompted his wife to call an ambulance and have him admitted to the hospital. Prior to admission to the hospital, his
only medication was insulin, although he often missed doses. He does not drink alcohol. He is 168 cm (5 ft 6 in) tall
and weighs 100 kg (220 lb); BMI is 36 kg/m2. His temperature is 37C (98.6F), pulse is 68/min, respirations are
18/min, and blood pressure is 150/85 mm Hg. Physical examination shows no abnormalities. On mental status
examination, he is tired and has a restricted affect. There is no evidence of suicidal ideation. Cognition is intact. His
fasting serum glucose concentration is 120 mg/dL. Which of the following is the most appropriate next step in
management?
(A)
(B)
(C)
(D)
(E)

15.

Frequent turning
Use of wet to dry dressings
Whirlpool therapy
Broad-spectrum antibiotic therapy
Surgical debridement

Adhere to the patient's wishes and discuss home-care options


Adhere to the patient's wishes on the condition that he agree to home nursing care
Schedule neuropsychological testing
Seek a court order to appoint a legal guardian
Involuntarily hold the patient in the hospital

A 32-year-old man who is a jackhammer operator comes to the physician because of pain and swelling of his right
arm for 3 days. The symptoms are moderately exacerbated by exertion. Examination of the right upper extremity
shows erythema and moderate edema. Capillary refill time is less than 3 seconds. Which of the following is the most
likely diagnosis?
(A)
(B)
(C)
(D)
(E)

Axillary-subclavian venous thrombosis


Deep venous valvular insufficiency
Superficial thrombophlebitis of the basilic vein
Superior vena cava syndrome
Thoracic outlet syndrome

13

16.

A 19-year-old college student comes to the physician because of progressive hair growth over her face and body
since the age of 16 years. She also has acne and oily skin. Menses have occurred at 30- to 90-day intervals since
menarche at the age of 14 years. She has no history of serious illness and takes no medications. She is 168 cm (5 ft 6
in) tall and weighs 88 kg (193 lb); BMI is 31 kg/m2. Her temperature is 37.2C (99F), pulse is 72/min, respirations
are 16/min, and blood pressure is 120/80 mm Hg. Physical examination shows coarse, pigmented hair over the chin
and upper lip, around both nipples, and along the midline of the lower abdomen. The remainder of the examination,
including pelvic examination, shows no abnormalities. Serum studies show:
Fasting glucose
Fasting insulin
Dehydroepiandrosterone sulfate
Follicle-stimulating hormone
17-Hydroxyprogesterone
Luteinizing hormone
Testosterone

95 mg/dL
7.5 U/mL (N=11240)
3 g/mL (N=0.55.4)
8 mIU/mL
160 ng/dL (N=20300)
10 mIU/mL
4.2 nmol/L (N<3.5)

Which of the following is the most appropriate pharmacotherapy?


(A)
(B)
(C)
(D)
(E)

17.

A 57-year-old woman comes to the physician because of an 8-week history of difficulty sleeping, fatigue, and
muscle tension. During this period, she also has had memory lapses, difficulty concentrating, and has been
reprimanded at work for arriving late. Over the past 2 weeks, she has had three episodes of palpitations and
shortness of breath that have awakened her from sleep. Her pulse is 80/min, and blood pressure is 110/90 mm Hg.
Physical examination shows no abnormalities. Mental status examination shows a depressed mood and constricted
affect. She says that she is no longer interested in activities that she used to enjoy. She has suicidal ideation without
a plan. Her hemoglobin concentration is 11 g/dL, and serum ferritin concentration is 140 ng/mL. Which of the
following is the most appropriate initial step in treatment?
(A)
(B)
(C)
(D)
(E)
(F)

18.

Bromocriptine
Clomiphene
Combination oral contraceptive
Dexamethasone
Gonadotropin-releasing hormone agonist

Acupuncture
Diazepam therapy
Donepezil therapy
Ferrous sulfate therapy
Ginkgo biloba extract therapy
Paroxetine therapy

During the past month, a 37-year-old woman has had epigastric pain 2 to 3 hours after eating and at night; she has a
feeling of fullness and bloating even when she eats small amounts. For 2 days, she has been unable to keep any food
"down" and has had repetitive vomiting between meals. Six months ago, she was diagnosed with a peptic ulcer and
was treated with a proton pump inhibitor and antibiotics. After 2 weeks of treatment, her symptoms were alleviated,
and she discontinued the medication due to the quantity of pills she had to take. Placement of a Foley catheter yields
no urine. This patient is most likely to have which of the following electrolyte profiles?

(A)
(B)
(C)
(D)
(E)

Na+
(mEq/L)
130
130
130
148
148

Cl
(mEq/L)
88
100
100
96
110

K+
(mEq/L)
2.8
4.2
4.4
2.3
4.8

14

HCO3
(mEq/L)
32
24
14
24
24

19.

Four days after undergoing open reduction and internal fixation of a fracture of the right femur sustained in a motor
vehicle collision, a 47-year-old man continues to have agitation and confusion despite treatment with haloperidol.
He has mild hypertension. Other medications include acetaminophen, atenolol, and prophylactic subcutaneous
heparin. His temperature is 37.2C (99F), pulse is 98/min, respirations are 24/min, and blood pressure is 168/98
mm Hg. During the examination, he is uncooperative and refuses to answer questions. Neurologic examination
shows tremulousness and no focal findings. He is oriented to person but not to place or time. A CT scan of the head
shows no abnormalities. Which of the following is the most likely cause of these findings?
(A)
(B)
(C)
(D)
(E)

20.

A 37-year-old woman is brought to the emergency department 45 minutes after she was found unconscious on her
apartment floor. Her coworkers became concerned when she did not arrive for work. On arrival, she is unable to
provide a history. Her pulse is 96/min, respirations are 12/min, and blood pressure is 124/58 mm Hg. Examination
shows erythema, warmth, and induration of the upper back, buttocks, and posterior thighs. Her serum creatine kinase
activity is 10,300 U/L. Urine toxicology screening is positive for opiates and cocaine. Urine dipstick is strongly
positive for blood. Microscopic examination of the urine shows pigmented granular casts and rare erythrocytes. This
patient is at increased risk for which of the following conditions over the next 24 hours?
(A)
(B)
(C)
(D)
(E)

21.

Acute respiratory distress syndrome


Acute tubular necrosis
Cerebral edema
Cerebral hemorrhage
Cocaine-induced cardiomyopathy

A 27-year-old woman comes to the physician for a follow-up examination. She has a 10-week history of persistent
nonproductive cough that is worse at night and a 1-month history of a hoarse voice. She otherwise feels well. She
has not had loss of appetite or change in exercise tolerance. She has never smoked. Empiric treatment with an oral
decongestant and albuterol inhaler has not improved her symptoms. She has no history of serious illness. Her
temperature is 37C (98.6F), pulse is 68/min, respirations are 12/min, and blood pressure is 110/76 mm Hg.
Cardiopulmonary examination and an x-ray of the chest show no abnormalities. Her FEV1 is normal. Which of the
following is the most appropriate next step in management?
(A)
(B)
(C)
(D)
(E)

22.

Adverse effect of medication


Alcohol withdrawal
Fat emboli
Sepsis
Subdural hematoma

24-Hour monitoring of esophageal pH


Echocardiography
CT scan of the chest
Inhaled corticosteroid therapy
Nitroglycerin therapy

A 22-year-old woman comes to the physician in October for a follow-up examination. She feels well. She has a 2year history of type 1 diabetes mellitus controlled with insulin. She had a normal Pap smear 3 months ago and saw
her ophthalmologist 6 months ago. Her 67-year-old grandmother has breast cancer. She is 168 cm (5 ft 6 in) tall and
weighs 57 kg (125 lb); BMI is 20 kg/m2. Her hemoglobin A1c is 6.2%, and fingerstick blood glucose concentration is
118 mg/dL. Which of the following health maintenance recommendations is most appropriate at this time?
(A)
(B)
(C)
(D)
(E)
(F)

Begin running for exercise


Dietary modification for weight loss
Human papillomavirus testing
Mammography
Influenza virus vaccine
Supplementation with vitamins C and D

15

23.

A 52-year-old man with alcoholism is brought to the emergency department because of a 2-day history of nausea,
vomiting, and increasingly severe abdominal pain that radiates to his left shoulder and back. He appears extremely
dehydrated and is short of breath. His temperature is 37.8C (100F), pulse is 120/min, respirations are 18/min, and
blood pressure is 80/60 mm Hg. Abdominal examination shows distention with epigastric tenderness. Bowel sounds
are decreased. Rectal examination shows no abnormalities. Test of the stool for occult blood is negative. Laboratory
studies show:
Hemoglobin
Leukocyte count
Serum
Ca2+
Amylase

5.5 g/dL
15,500/mm3
7.5 mg/dL
750 U/L

A CT scan of the abdomen is shown. Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)

24.

Acute portal vein thrombosis


Hemorrhagic pancreatitis
Perforated posterior gastric ulcer
Ruptured gastric varices
Splenic artery rupture

A 72-year-old woman with advanced ovarian cancer metastatic to the liver is brought to the physician by her son
because she cries all the time and will not get out of bed. On a 10-point scale, she rates the pain as a 1 to 2. She also
has hypertension and major depressive disorder. She has received chemotherapy for 2 years. Current medications
also include oxycodone (10 mg twice daily), hydrochlorothiazide (25 mg/d), and fluoxetine (20 mg/d). She is 165
cm (5 ft 5 in) tall and weighs 66 kg (145 lb); BMI is 24 kg/m2. Her temperature is 37C (98.6F), pulse is 110/min,
respirations are 12/min, and blood pressure is 120/80 mm Hg. Examination shows a firm, distended abdomen with
moderate tenderness over the liver. On mental status examination, she is oriented to person, place, and time. She has
good eye contact but appears sad and cries easily. Which of the following is the most appropriate next step in
management?
(A)
(B)
(C)
(D)
(E)

Reassurance
Assess for suicidal ideation
Begin dextroamphetamine therapy
Increase oxycodone dosage
Restart chemotherapy

16

25.

A previously healthy 19-year-old college student comes to student health services 24 hours after the onset of
headache, stiff neck, and sensitivity to light. She does not recall any sick contacts. She had chickenpox at the age of
7 years. Her most recent examination 1 year ago included PPD skin testing and showed no abnormalities. She takes
a daily multivitamin and an herbal weight-loss preparation. She received all appropriate immunizations during
childhood but has not received any since then. She does not smoke, drink alcohol, or use illicit drugs. There is no
family history of serious illness. She appears lethargic. Her temperature is 39.1C (102.4F), pulse is 112/min,
respirations are 20/min, and blood pressure is 100/68 mm Hg. Examination shows diffuse petechiae. Kernig and
Brudzinski signs are present. The remainder of the examination shows no abnormalities. A lumbar puncture is
performed. Cerebrospinal fluid (CSF) analysis shows numerous segmented neutrophils and a decreased glucose
concentration. A Gram stain of the CSF shows gram-negative cocci. Which of the following is the most appropriate
pharmacotherapy?
(A)
(B)
(C)
(D)
(E)

26.

A 32-year-old man is brought to the emergency department 30 minutes after he drove his motorcycle into a guardrail
at a high speed. He was riding without a helmet. On arrival, his pulse is 100/min, respirations are 14/min, and blood
pressure is 120/80 mm Hg. Examination shows a deep perineal laceration. There is mild suprapubic tenderness. He
voids 25 mL of bloody urine. An x-ray of the pelvis shows a widened pubic symphysis. Which of the following is
the most appropriate next step in diagnosis?
(A)
(B)
(C)
(D)
(E)

27.

Measurement of urine hemoglobin concentration


Cystography
Urethrography
Placement of a urinary catheter
Intravenous pyelography

A study is conducted to assess the effectiveness of a new drug for the treatment of type 2 diabetes mellitus. A total
of 1000 patients with type 2 diabetes mellitus are enrolled. Patients are randomly assigned to receive the new drug
or standard treatment. The alpha and beta values for calculating probability are 0.05 and 0.20, respectively. Results
show that the new drug is significantly better than standard treatment. If this study had been performed in a
population of only 500 patients, which of the following would have been most likely to increase?
(A)
(B)
(C)
(D)
(E)

28.

Ceftriaxone
Clindamycin
Erythromycin
Metronidazole
Vancomycin

Chance of a type I error


Chance of a type II error
Power of the study
Sensitivity of the study
Specificity of the study

A 22-year-old man is brought to the emergency department 30 minutes after he sustained a gunshot wound to the
abdomen. His pulse is 120/min, respirations are 28/min, and blood pressure is 70/40 mm Hg. Breath sounds are
normal on the right and decreased on the left. Abdominal examination shows an entrance wound in the left upper
quadrant at the midclavicular line below the left costal margin. There is an exit wound laterally in the left axillary
line at the 4th rib. Intravenous fluid resuscitation is begun. Which of the following is the most appropriate next step
in management?
(A)
(B)
(C)
(D)
(E)

Upright x-ray of the chest


CT scan of the chest
Intubation and mechanical ventilation
Peritoneal lavage
Left tube thoracostomy

17

29.

A 42-year-old man comes to the physician for a routine follow-up examination. He has a 15-year history of
type 1 diabetes mellitus and an 8-year history of hypertension. Current medications include insulin, lisinopril, and
hydrochlorothiazide. He is 173 cm (5 ft 8 in) tall and weighs 68 kg (150 lb); BMI is 23 kg/m 2. His pulse is 80/min,
and blood pressure is 124/74 mm Hg. Examination of the lower extremities shows hair loss over the shins. No other
abnormalities are noted. His hemoglobin A1c is 6.3%. Which of the following is most appropriate to reduce diabetic
complications in this patient?
(A)
(B)
(C)
(D)
(E)

30.

A previously healthy 42-year-old woman comes to the physician because of a 6-month history of difficulty
swallowing and regurgitation of undigested food. She also has had color changes and pain in her fingertips when
they are exposed to cold temperatures. She has not had nausea, abdominal pain, diarrhea, or constipation.
Examination of the face shows thick, tightly bound skin. The fingertips are tapered and covered with ischemic
ulcerations. There are telangiectasias diffusely distributed over the trunk and upper extremities. Funduscopic
examination shows retinal hemorrhages bilaterally. Which of the following is the most appropriate pharmacotherapy
for this patient's pain and ulcerations?
(A)
(B)
(C)
(D)
(E)

31.

Enalapril
Methotrexate
Nifedipine
Prednisone
Propranolol

An 18-year-old man is brought to the emergency department 10 minutes after he sustained a stab wound to his chest.
On arrival, he is unresponsive to painful stimuli. His pulse is 130/min, respirations are 8/min and shallow, and
palpable systolic blood pressure is 60 mm Hg. He is intubated and mechanically ventilated, and infusion of 0.9%
saline is begun. After 5 minutes, his pulse is 130/min, and blood pressure is 70/40 mm Hg. Examination shows a 2cm wound at the left sixth intercostal space at the midclavicular line. There is jugular venous distention. Breath
sounds are normal. The trachea is at the midline. Heart sounds are not audible. Which of the following is the most
appropriate next step in management?
(A)
(B)
(C)
(D)
(E)

32.

Reduction of systolic blood pressure to less than 120 mm Hg


Annual ophthalmologic examination
Annual exercise stress test
Add metformin to the regimen
Switch from lisinopril to atenolol

Chest x-ray
Echocardiography
Bronchoscopy
Pericardiocentesis
Placement of a right chest tube

A previously healthy 27-year-old man comes to the physician 4 weeks after noticing three nontender lesions on his
penis. He says they have not changed in size. He is sexually active with multiple male and female partners and uses
condoms inconsistently. He takes no medications. He drinks two to five beers on social occasions. He occasionally
smokes marijuana. His temperature is 36.9C (98.4F). There is no lymphadenopathy. Examination shows three
sessile, flesh-colored lesions on the shaft of the penis that are 10 mm in diameter. On application of a dilute solution
of acetic acid, the lesions turn white. The remainder of the examination shows no abnormalities. Which of the
following is the most appropriate next step in management?
(A)
(B)
(C)
(D)
(E)

Topical ganciclovir therapy


Oral acyclovir therapy
Oral doxycycline therapy
Intramuscular penicillin therapy
Cryotherapy

18

33.

A 47-year-old man comes to the physician 12 hours after the sudden onset of a severe occipital headache and stiff
neck. He has not had any other symptoms and has no history of severe headache. He has hypertension and
gastroesophageal reflux disease. Current medications include hydrochlorothiazide and ranitidine. He is oriented to
person, place, and time. His temperature is 36.7C (98.1F), pulse is 100/min, and blood pressure is 160/90 mm Hg.
Range of motion of the neck is decreased due to pain. Neurologic examination shows no focal findings. Which of
the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)

34.

A 32-year-old woman, gravida 2, para 1, at 8 weeks' gestation comes to the physician for her first prenatal visit. She
delivered her first child spontaneously at 34 weeks' gestation; pregnancy was complicated by iron deficiency
anemia. She has no other history of serious illness. Her blood pressure is 100/70 mm Hg. Examination shows no
abnormalities. Ultrasonography shows a dichorionic-diamniotic twin intrauterine pregnancy consistent in size with
an 8-week gestation. This patient is at increased risk for which of the following complications?
(A)
(B)
(C)
(D)
(E)

35.

Cluster headache
Meningitis
Migraine
Subarachnoid hemorrhage
Tension-type headache

Abruptio placentae
Fetal chromosome abnormality
Hyperthyroidism
Preterm labor and delivery
Twin transfusion syndrome

A 27-year-old woman comes to the physician because she has been unable to move the left side of her face for the
past 2 days. Two weeks ago, she had a 3-day episode of flu-like symptoms that resolved without treatment. She has
a history of impaired glucose tolerance. She is sexually active with one male partner and uses an oral contraceptive;
they do not use condoms. She says she sometimes eats too much and occasionally consumes raw shellfish. She lives
in Minnesota and hikes a wooded path with her dog daily to go swimming in a lake. She is 157 cm (5 ft 2 in) tall and
weighs 77 kg (170 lb); BMI is 31 kg/m2. Examination shows an inability to wrinkle the left side of the forehead and
an asymmetric smile. The remainder of the examination shows no abnormalities. Which of the following is the
strongest predisposing factor for this patient's condition?
(A)
(B)
(C)
(D)
(E)
(F)

Hiking
Oral contraceptive use
Overeating
Shellfish ingestion
Swimming in a lake
Unprotected sexual intercourse

19

The response options for the next 2 items are the same. Select one answer for each item in the set.
(A)
(B)
(C)
(D)
(E)
(F)
(G)

Autoimmune disorder
Bacterial infection
Metabolic process
Obstruction
Physiologic process
Toxin exposure
Viral infection

For each patient with jaundice, select the most likely mechanism.
36.

A 3-year-old girl is brought to the physician because of a 3-day history of dark urine and a 1-day history of yellow
skin and pale stools. One week ago, she had mild abdominal pain, vomiting, and diarrhea that have now resolved.
Several other children at the day care she attends had similar symptoms 2 weeks ago. She has received her complete
hepatitis B immunization series. She is at the 50th percentile for height and weight. Examination shows pale yellow
skin and mild scleral icterus. There is mild tenderness of the liver to palpation.

37.

A previously healthy 3-week-old newborn is brought to the emergency department because of a 2-day history of
irritability and yellow skin. During this period, he has had dark urine and pale stools. He was born at term following
an uncomplicated pregnancy and delivery. His mother was immunized against hepatitis B prior to conception. He is
at the 50th percentile for length, weight, and head circumference. His temperature is 37.3C (99.1F), pulse is
120/min, respirations are 40/min, and blood pressure is 70/30 mm Hg. His skin is diffusely pale yellow. Abdominal
examination shows mild distention and a subhepatic mass.

The response options for the next 2 items are the same. Select one answer for each item in the set.
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)

Increased intracranial pressure


Migraine
Occipital neuralgia
Post-traumatic headache
Subarachnoid hemorrhage
Subdural hematoma
Temporomandibular joint syndrome
Tension-type headache

For each patient with headache, select the most likely diagnosis.
38.

A 27-year-old man comes to the physician because of persistent headaches since a motor vehicle collision 2 weeks
ago. In the collision, he struck his head on the windshield but did not lose consciousness. The headaches are
generalized with a constant pressure-like pain. He also has had memory loss and difficulty sleeping. Neurologic
examination and an MRI of the brain show no abnormalities.

39.

A 32-year-old woman comes to the physician because of an 8-month history of moderately severe, bilateral, diffuse
headaches that last "all day, every day." They are not responsive to over-the-counter medications. She has not had
nausea, vomiting, or aura. She appears mildly depressed. Neurologic examination shows no abnormalities.

20

The response options for the next 2 items are the same. Select one answer for each item in the set.

(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(I)
(J)
(K)

Alcohol withdrawal
Coronary insufficiency
Hyperthyroidism
Hypoglycemia
Major depressive disorder
Panic disorder
Paroxysmal atrial tachycardia
Pheochromocytoma
Post-traumatic stress disorder
Pulmonary embolus
Somatization disorder

For each patient with anxiety, select the most likely diagnosis.
40.

A 33-year-old woman comes to the emergency department 30 minutes after the sudden onset of chest pain,
palpitations, shortness of breath, numbness and tingling in both arms, and fear of going crazy. She has visited local
emergency departments several times over the past 3 months for similar symptoms that resolved within 1 hour. She
uses an oral contraceptive. She drinks two beers daily and six beers on the weekend. She has no history of medical
problems. Her mother and sisters have a history of anxiety. Her pulse is 90/min, respirations are 18/min, and blood
pressure is 130/90 mm Hg. Physical examination, laboratory studies, and an ECG show no abnormalities.

41.

A 35-year-old woman comes to the physician because of nervousness, tremors, emotional lability, and excessive
sweating for 3 weeks; she has had a 4.5-kg (10-lb) weight loss during this period. She has no personal or family
history of psychiatric disorders. Her pulse is 95/min, respirations are 12/min, and blood pressure is 120/80 mm Hg.
Examination shows warm and moist skin, a fine tremor of the fingers and tongue, and hyperreflexia.

21

Sample Questions
Block 2 (Questions 42-86)

42.

A 67-year-old woman comes to the physician for a follow-up examination. She had a pulmonary embolism and
required treatment in the hospital for 3 weeks. She had a retroperitoneal hemorrhage; anticoagulant therapy was
temporarily discontinued, and she underwent placement of an inferior vena cava (IVC) filter. She had a hematoma
that was resolving on discharge from the hospital 2 weeks ago. Today, she says she has had a persistent sensation of
tingling and numbness of her left thigh that she did not report in the hospital because she thought it would go away;
the sensation has improved somewhat during the past week. Her only medication is warfarin. Vital signs are within
normal limits. Examination of the skin shows no abnormalities. Muscle strength is normal. Sensation to light touch
is decreased over a 5 x 5-cm area on the lateral aspect of the left anterior thigh. Which of the following is the most
likely cause of this patient's decreased sensation?
(A)
(B)
(C)
(D)
(E)
(F)

43.

A 37-year-old woman comes to the physician because of shortness of breath for 3 months. Her symptoms increase
with exertion. She also has had difficulty walking because of ankle pain. Two months ago, she had painful red spots
on her legs for several weeks. She has not had a sore throat. She takes acetaminophen for aches and pains. Her
temperature is 37.4C (99.3F), pulse is 90/min, respirations are 18/min, and blood pressure is 140/90 mm Hg. The
lungs are clear to auscultation, and cardiac examination shows no abnormalities. An x-ray of the chest shows
bilateral hilar adenopathy. Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)

44.

Cerebral infarction during the hospitalization


Complication of the IVC filter placement
Compression of the lateral femoral cutaneous nerve
Hematoma of the left thigh
Spinal cord infarct
Vitamin B12 (cobalamin) deficiency

Cat-scratch disease
Chronic lymphocytic leukemia
Hodgkin disease
Rubella
Sarcoidosis
Syphilis
Systemic lupus erythematosus
Tuberculosis

A 52-year-old woman has had dyspnea and hemoptysis for 1 month. She has a history of rheumatic fever as a child
and has had a cardiac murmur since early adulthood. Her temperature is 36.7C (98F), pulse is 130/min and
irregularly irregular, respirations are 20/min, and blood pressure is 98/60 mm Hg. Jugular venous pressure is not
increased. Bilateral crackles are heard at the lung bases. There is an opening snap followed by a low-pitched
diastolic murmur at the third left intercostal space. An x-ray of the chest shows left atrial enlargement, a straight left
cardiac border, and pulmonary venous engorgement. Which of the following is the most likely explanation for these
findings?
(A)
(B)
(C)
(D)
(E)

Aortic valve insufficiency


Aortic valve stenosis
Mitral valve insufficiency
Mitral valve stenosis
Tricuspid valve insufficiency

22

45.

A 16-year-old girl is brought to the physician because of intermittent pain and swelling of both ankles over the past
month. She is currently not in pain. When the pain occurs, it is so severe that she is unable to walk. There is no
associated fever or chills. She is sexually active and has had one sexual partner for 12 months. Her temperature is
37C (98.6F), pulse is 80/min, and blood pressure is 145/87 mm Hg. Examination shows no abnormalities or
tenderness of the ankle joints. There is a nonpainful ulcer on the oral buccal mucosa. The lungs are clear to
auscultation. Cardiac examination shows no abnormalities. Laboratory studies show:
Leukocyte count
Segmented neutrophils
Eosinophils
Lymphocytes
Monocytes
Platelet count
Erythrocyte sedimentation rate
Serum
Antinuclear antibodies
Anti-DNA antibodies
Rapid plasma reagin
Rheumatoid factor
Urine
Protein
RBC casts
RBC
WBC

4000/mm3
65%
3%
25%
7%
60,000/mm3
100 mm/h
1:320
positive
1:16
negative
3+
negative
none
1020/hpf

X-rays of the ankles show no abnormalities other than tissue swelling. Which of the following is the most likely
diagnosis?
(A)
(B)
(C)
(D)
(E)

46.

Disseminated gonococcal disease


Polyarticular arthritis
Reactive arthritis
Secondary syphilis
Systemic lupus erythematosus

A 30-year-old woman comes to the physician because of intermittent throbbing headaches, sweating, and pallor over
the past 3 months. She has had several blood pressure measurements that fluctuate from 110/80 mm Hg to 160/108
mm Hg. Her pulse is 100/min, and blood pressure now is 138/88 mm Hg. Serum studies show:
Na+
Cl
K+
HCO3
Urea nitrogen
Creatinine

140 mEq/L
110 mEq/L
4.5 mEq/L
26 mEq/L
14 mg/dL
1 mg/dL

Which of the following is the most likely location of the abnormality?


(A)
(B)
(C)
(D)
(E)
(F)

Adrenal cortex
Adrenal medulla
Aorta
Renal arterioles
Renal glomeruli
Thyroid gland

23

47.

A 64-year-old woman comes to the physician because of a 5-month history of increasing shortness of breath, sore
throat, and a cough productive of a small amount of white phlegm. Over the past week, she has had nausea related to
excess coughing. Over the past year, she has had a 3.2-kg (7-lb) weight loss. She has asthma treated with
theophylline and inhaled -adrenergic agonists and corticosteroids. She has smoked one pack of cigarettes daily for
44 years and drinks one alcoholic beverage daily. She appears thin. Examination shows a 2-cm, nontender lymph
node in the right supraclavicular area. Examination shows no other abnormalities. An x-ray of the chest shows a
large right lower lobe density. A CT scan of the chest shows a 7.5 x 7.5 x 6-cm right lower lobe mass with some
scattered calcifications. The lesion abuts the posterior chest wall without clear invasion. There are right lower
peritracheal, precarinal, right hilar, and subcarinal lymph nodes. There is a 1.5-cm mass in the right adrenal gland. A
biopsy specimen of the lung mass is most likely to show which of the following?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)

48.

A 60-year-old man has had painful skin with exfoliation of the skin and mucous membranes for 1 day. He has been
taking allopurinol and probenecid for 2 weeks because of gouty arthritis. There is diffuse exfoliation of the skin with
oozing of serous fluid. The mucous membranes of the mouth are erythematous and exfoliated. There are no target
lesions. Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)

49.

Bullous pemphigoid
Erythema multiforme
Pemphigus erythematosus
Staphylococcal scalded-skin syndrome
Toxic epidermal necrolysis

A 4-year-old boy is brought to the physician because of temperatures to 39.4C (102.9F) for 8 days. Examination
shows anterior cervical lymphadenopathy, nonexudative conjunctivitis bilaterally, a strawberry tongue, an
erythematous truncal rash, and edema of the hands and feet. Which of the following is the most appropriate
pharmacotherapy to prevent complications of this illness?
(A)
(B)
(C)
(D)
(E)

50.

B-cell lymphoma
Lung abscess
Mesothelioma
Metastatic adenocarcinoma of the breast
Multiple endocrine neoplasia
Non-small cell lung carcinoma
Sarcoidosis
Tuberculosis

Intravenous immune globulin


Intravenous penicillin
Intravenous prednisone
Oral isoniazid
Oral rifampin

A 20-year-old man has had frequent upper respiratory tract infections over the past 4 years. He has daily purulent
sputum and has noted decreased exercise tolerance over the past 2 years. He and his wife have been unable to
conceive because of his low sperm count. Scattered expiratory wheezing and rhonchi are heard throughout both lung
fields. An x-ray of the chest shows hyperinflation. Spirometry shows a decreased FEV 1:FVC ratio. Which of the
following is most likely to confirm the diagnosis?
(A)
(B)
(C)
(D)
(E)

Arterial blood gas analysis


Examination of sputum for eosinophils
Sweat chloride test
Sputum cytology
Bronchoscopy

24

51.

A 27-year-old nulligravid woman comes to the physician because of a 1-year history of irregular heavy menstrual
bleeding. She has been otherwise healthy. Menses occur at irregular 15- to 45-day intervals and last 3 to 7 days;
menses had previously occurred at regular 28-day intervals with moderate flow. Her last menstrual period was
4 weeks ago. She is sexually active and does not use contraception. Her temperature is 37C (98.6F), pulse is
80/min, respirations are 20/min, and blood pressure is 120/80 mm Hg. Physical examination shows no
abnormalities. Pelvic examination shows clear cervical mucus. Serum studies show:
3 U/mL
5 mIU/mL
18 ng/mL
0.5 ng/mL (menstrual cycle day 30: follicular N<3; luteal N>35)

Thyroid-stimulating hormone
Follicle-stimulating hormone
Prolactin
Progesterone

Pelvic ultrasonography shows no abnormalities. Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)

52.

A 57-year-old man comes to the emergency department because of cramping in his hands and feet and numbness
and tingling around his lips and in his fingers; these symptoms occurred intermittently for 6 months but have been
progressively severe during the past 2 weeks. He also has had a 13-kg (30-lb) weight loss and bulky, foul-smelling
stools that do not flush easily. He has a 10-year history of drinking 8 to 10 beers daily. He has been hospitalized
twice for severe abdominal pain 4 and 6 years ago. His pulse is 80/min, and blood pressure is 105/65 mm Hg. He
appears cachectic and chronically ill. The abdomen is nontender. Deep tendon reflexes are 4+ bilaterally. Chvostek
and Trousseau signs are present. His serum calcium concentration is 6.5 mg/dL. Which of the following is the most
likely diagnosis?
(A)
(B)
(C)
(D)

53.

Adenomyosis
Anovulation
Endometrial polyp
Leiomyoma uteri
Pregnancy

Hypomagnesemia
Hypoparathyroidism
Osteomalacia
Vitamin D deficiency

A 62-year-old woman comes to the physician for a routine health maintenance examination. On questioning, she has
had fatigue, constipation, and a 9-kg (20-lb) weight gain during the past year. She receives estrogen replacement
therapy. Serum lipid studies were within the reference range 5 years ago. She is 157 cm (5 ft 2 in) tall and weighs 77
kg (170 lb); BMI is 31 kg/m2. Physical examination shows no other abnormalities. Serum lipid studies today show:
Total cholesterol
HDL-cholesterol
LDL-cholesterol
Triglycerides

269 mg/dL
48 mg/dL
185 mg/dL
180 mg/dL

Which of the following is the most likely cause?


(A)
(B)
(C)
(D)
(E)
(F)

Alcohol
Diabetes mellitus
Estrogen deficiency
Estrogen replacement therapy
Hypothyroidism
Thiazide diuretic therapy

25

54.

A 45-year-old woman has a 2-week history of increased anxiety, abdominal discomfort, irritability, and difficulty
concentrating; she was robbed at knifepoint in a parking lot 3 weeks ago. She takes levothyroxine for
hypothyroidism and uses an over-the-counter inhaler as needed for exercise-induced asthma. Her blood pressure is
140/80 mm Hg, and pulse is 100/min. Examination shows dry skin and hair. She is cooperative but appears anxious,
glancing around quickly when a loud noise is heard outside the office. Leukocyte count is 12,000/mm3, and serum
thyroid-stimulating hormone concentration is 5.0 U/mL. An ECG shows sinus tachycardia. Which of the following
is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)

55.

A previously healthy 17-year-old girl comes to the physician because of a 1-week history of itching and progressive
rash. She has no history of skin problems or associated symptoms. She takes no medications. Her sister with whom
she shares a room had similar symptoms during the previous week. The patient's temperature is 36.8C (98.2F).
There are multiple 2- to 5-mm erythematous papules over the trunk, especially at the waistline, and over the
forearms, hands, and fingers. There is no lymphadenopathy or hepatosplenomegaly. Which of the following is the
most likely causal organism?
(A)
(B)
(C)
(D)
(E)

56.

Epstein-Barr virus
Group A streptococcus
Measles virus
Sarcoptes scabiei
Varicella-zoster virus

A previously healthy 20-year-old college student comes to the emergency department because she has been unable
to urinate for 8 hours. She has a 2-day history of fever, fatigue, severe burning with urination, and pain in the genital
area. She is sexually active and uses a diaphragm for contraception. She takes no medications. She appears
uncomfortable. Her temperature is 38.7C (101.7F), pulse is 110/min, and blood pressure is 110/70 mm Hg.
Abdominal examination shows a large, cystic, midline pelvic mass. The groin nodes are enlarged and tender. Pelvic
examination shows erythematous external genitalia with extensive ulceration. The lesions extend into the vagina.
Internal examination is not possible due to patient discomfort. Which of the following is the most appropriate initial
step in management?
(A)
(B)
(C)
(D)
(E)

57.

Acute stress disorder


Agoraphobia
Generalized anxiety disorder
Hypothyroidism
Panic disorder

Measurement of serum urea nitrogen concentration


Vaginal cultures
Intravenous pyelography
Renal ultrasonography
Placement of a Foley catheter

A 3-year-old girl is brought to the physician because of fever and left ear pain for 3 days. She has been treated with
amoxicillin for the past 5 days for left otitis media. Her temperature is 38.5C (101.3F), pulse is 100/min,
respirations are 20/min, and blood pressure is 80/60 mm Hg. Examination shows the left ear displaced forward and
laterally from the head. There is edema and tenderness behind the left ear. Otoscopic examination shows a red, dull,
left tympanic membrane that does not move. Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)

Acoustic neuroma
Labyrinthitis
Lateral sinus thrombosis
Mastoiditis
Rhabdomyosarcoma

26

58.

A 47-year-old woman with end-stage renal disease comes to the physician because of increased shortness of breath
since her last hemodialysis 2 days ago. Her pulse is 88/min and regular, respirations are 26/min and slightly labored,
and blood pressure is 176/110 mm Hg. Examination shows jugular venous distention and pitting edema below the
knees. Diffuse crackles are heard. Cardiac examination shows no murmurs, rubs, or gallops. Laboratory studies
show:
Serum
Na+
138 mEq/L
Cl
100 mEq/L
Arterial blood gas analysis on room air:
pH
PCO2
PO2
HCO3

7.30
28 mm Hg
88 mm Hg
14 mEq/L

Which of the following is the most likely acid-base status of this patient?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(I)

59.

A 37-year-old woman, gravida 5, para 4, at 34 weeks' gestation comes to the emergency department because of
vaginal bleeding for 2 hours. She has had no prenatal care. Her second child was delivered by lower segment
transverse cesarean section because of a nonreassuring fetal heart rate; her other three children were delivered
vaginally. Her pulse is 92/min, respirations are 18/min, and blood pressure is 134/76 mm Hg. The abdomen is
nontender, and no contractions are felt. There is blood on the vulva, the introitus, and on the medial aspect of each
thigh. The fetus is in a transverse lie presentation. The fetal heart rate is 144/min. Which of the following is the most
likely diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)

60.

Metabolic acidosis, respiratory compensation


Metabolic acidosis, uncompensated
Metabolic alkalosis, respiratory compensation
Metabolic alkalosis, uncompensated
Respiratory acidosis, renal compensation
Respiratory acidosis, uncompensated
Respiratory alkalosis, renal compensation
Respiratory alkalosis, uncompensated
Normal acid-base balance

Abruptio placentae
Amniotic fluid embolism
Latent phase of labor
Placenta previa
Ruptured uterus
Ruptured vasa previa

A 47-year-old man is brought to the emergency department 2 hours after the sudden onset of shortness of breath,
severe chest pain, and sweating. He has no history of similar symptoms. He has hypertension treated with
hydrochlorothiazide. He has smoked one pack of cigarettes daily for 30 years. His pulse is 110/min, respirations are
24/min, and blood pressure is 110/50 mm Hg. A grade 3/6, diastolic blowing murmur is heard over the left sternal
border and radiates to the right sternal border. Femoral pulses are decreased bilaterally. An ECG shows left
ventricular hypertrophy. Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)

Acute myocardial infarction


Aortic dissection
Esophageal rupture
Mitral valve prolapse
Pulmonary embolism

27

61.

A 67-year-old woman comes to the physician 1 month after noticing a nontender nodule on the back of her left hand.
She initially thought it was an insect bite, but it has grown in size over the past week. It bleeds when she picks at it.
She has no history of serious illness. She lives in a retirement community in Florida and frequently plays golf and
tennis. Examination of the dorsum of the left hand shows a 2.5-cm lesion. Photographs of the lesion are shown.
Which of the following is the most appropriate next step in management?
(A)
(B)
(C)
(D)
(E)

62.

A 21-year-old woman comes to the physician for preconceptional advice. She is recently married and would like to
conceive within the next year. She does not eat meat, fish, or dairy products and wishes to decrease the risks of her
diet on her baby. Menses occur at regular 28-day intervals and last 5 days. She does not smoke or drink alcohol. She
takes no medications. She is 157 cm (5 ft 2 in) tall and weighs 50 kg (110 lb); BMI is 20 kg/m 2. Physical
examination shows no abnormalities. Pelvic examination shows a normal appearing vagina, cervix, uterus, and
adnexa. Which of the following is most likely to decrease the risk of fetal anomalies in this patient?
(A)
(B)
(C)
(D)
(E)

63.

Observation
Topical application of fluorouracil
Sentinel lymph node biopsy
Cryosurgery
Excision of the lesion

Adjusting diet to include more sources of protein during the first trimester
Beginning folic acid supplementation prior to conception
Calcium supplementation during the first trimester
Iron supplementation during the first trimester
Soy protein shakes throughout pregnancy and lactation

A 5-year-old boy is brought to the physician because of a 2-day history of fever and painful swelling of the left
ankle. He has had recurrent cervical lymphadenitis and pneumonia since infancy. Two years ago, a culture from an
abscess in the cervical region grew Staphylococcus aureus. His temperature is 38C (100.4F). Examination shows a
tender, erythematous, edematous left ankle; there is point tenderness over the medial malleolus. A bone scan shows
increased uptake in the left lower tibial metaphysis. Culture of bone aspirate grows Serratia marcescens. Nitroblue
tetrazolium test shows no color change. Which of the following is the most likely mechanism for these findings?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)

Adenosine deaminase deficiency


Consumption of complement
Defective opsonization
Destruction of CD4+ T lymphocytes
Developmental arrest of maturation of B lymphocytes
Dysmorphogenesis of the third and fourth pharyngeal pouches
Impaired chemotaxis
Impaired phagocytic oxidative metabolism

28

64.

A 42-year-old woman comes to the physician because of an 8-week history of intermittent nausea and abdominal
pain that occurs 20 to 30 minutes after eating. The pain extends from the epigastrium to the right upper quadrant and
is sometimes felt in the right scapula; it lasts about 30 minutes and is not relieved by antacids. The last episode
occurred after she ate a hamburger and french fries. She has not had vomiting. She is currently asymptomatic. She is
165 cm (5 ft 5 in) tall and weighs 104 kg (230 lb); BMI is 38 kg/m2. Examination shows no other abnormalities.
Which of the following is the most appropriate next step in management?
(A)
(B)
(C)
(D)
(E)
(F)

65.

A 27-year-old woman, gravida 2, para 1, at 12 weeks' gestation comes to the physician for a prenatal visit. She feels
well. Pregnancy and delivery of her first child were uncomplicated. Medications include folic acid and a
multivitamin. Her temperature is 37.2C (99F), and blood pressure is 108/60 mm Hg. Pelvic examination shows a
uterus consistent in size with a 12-week gestation. Urine dipstick shows leukocyte esterase; urinalysis shows WBCs
and rare gram-negative rods. Which of the following is the most appropriate next step in management?
(A)
(B)
(C)
(D)
(E)
(F)

66.

Recommend drinking 8 oz of cranberry juice daily


Oral amoxicillin therapy
Oral metronidazole therapy
Intravenous cefazolin therapy
Intravenous pyelography
Cystoscopy

A previously healthy 15-year-old boy is brought to the emergency department in August 1 hour after the onset of
headache, dizziness, nausea, and one episode of vomiting. His symptoms began during the first hour of full-contact
football practice in full uniform. He reported feeling weak and faint but did not lose consciousness. He vomited once
after drinking water. On arrival, he is diaphoretic. He is not oriented to person, place, or time. His temperature is
39.5C (103.1F), pulse is 120/min, respirations are 40/min, and blood pressure is 90/65 mm Hg. Examination,
including neurologic examination, shows no other abnormalities. Which of the following is the most appropriate
next step in management?
(A)
(B)
(C)
(D)
(E)

67.

Abdominal ultrasonography of the right upper quadrant


Upper gastrointestinal series with small bowel follow-through
CT scan of the abdomen
Endoscopic retrograde cholangiopancreatography
Elective cholecystectomy
Immediate cholecystectomy

Obtain a CT scan of the head


Administer sodium chloride tablets
Administer intravenous fluids
Immerse the patient in an ice water bath
Obtain a lumbar puncture

A 67-year-old woman comes to the physician because of easy bruising for 4 months. She has a history of
lung cancer treated with radiation therapy 6 months ago. She has a 2-year history of hypertension treated with a
thiazide diuretic and an angiotensin-converting enzyme (ACE) inhibitor. Examination, including neurologic
examination, shows no abnormalities except for multiple ecchymoses. Her hemoglobin concentration is 13 g/dL,
leukocyte count is 5000/mm3, and platelet count is 35,000/mm3. A serum antiplatelet antibody assay is negative.
Which of the following is the most appropriate next step in diagnosis?
(A)
(B)
(C)
(D)
(E)

Bone scan
CT scan of the abdomen
CT scan of the chest
Bronchoscopy
Bone marrow aspiration

29

68.

A 22-year-old man comes to the physician for a routine health maintenance examination. He feels well. He has had a
painless left scrotal mass since childhood. Examination shows a 6-cm, soft, nontender left scrotal mass that
transilluminates; there are no bowel sounds in the mass. Examination of the testis shows no abnormalities. Which of
the following is the most likely cause of the mass?
(A)
(B)
(C)
(D)
(E)

69.

A previously healthy 22-year-old college student is brought to the emergency department by her parents 20 minutes
after they observed her having a seizure. After the seizure, she was confused and had difficulty thinking of some
words. She has had a headache, cough, and fever for 3 days treated with acetaminophen and dextromethorphan. Her
temperature is 38.9C (102F). Neurologic examination shows diffuse hyperreflexia. On mental status examination,
she is confused and has short-term memory deficits. She has difficulty naming objects and makes literal paraphasic
errors. An MRI of the brain shows bitemporal hyperintensities. A lumbar puncture is done; cerebrospinal fluid
analysis shows an erythrocyte count of 340/mm3, a leukocyte count of 121/mm3 (88% monocytes), and a protein
concentration of 78 mg/dL. Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)

70.

Bacterial meningitis
Dextromethorphan intoxication
Herpes simplex encephalitis
HIV encephalopathy
Reye syndrome
Syphilis

A 27-year-old man is brought to the emergency department by his sister because of increasing confusion for
10 hours. He is unable to answer questions. His sister states that he recently saw a psychiatrist for the first time
because of hearing voices; he was prescribed a medication, but she is not sure what it is. She says that he has a
history of excessive drinking, and she thinks that he has also experimented with illicit drugs. He appears acutely ill.
His temperature is 39.1C (102.3F), pulse is 124/min, and blood pressure is 160/102 mm Hg. Examination shows
profuse diaphoresis and muscle rigidity. His neck is supple. The abdomen is soft and nontender. Mental status
examination shows psychomotor agitation alternating with lethargy. His leukocyte count is 15,600/mm3, and serum
creatine kinase activity is 943 U/L. Which of the following is the most likely explanation for this patient's
symptoms?
(A)
(B)
(C)
(D)
(E)

71.

Accumulation of scrotal adipose tissue


Cryptorchidism of the left testis
Dilation of the pampiniform plexus of veins around the testis
Persistence of a patent processus vaginalis
Torsion of the left testis

Amphetamine intoxication
Bacterial meningitis
Delirium tremens
Neuroleptic malignant syndrome
Sepsis

A 37-year-old man comes to the physician because of nonradiating low back pain for 3 days. The pain began after
he worked in his yard. He has not had any change in bowel movements or urination. He had one similar episode 3
years ago that resolved spontaneously. Vital signs are within normal limits. Examination of the back shows bilateral
paravertebral muscle spasm. Range of motion is limited by pain. Straight-leg raising is negative. In addition to
analgesia, which of the following is the most appropriate next step in management?
(A)
(B)
(C)
(D)
(E)

Bed rest
Regular activity
X-rays of the spine
MRI of the spine
Lumbar spine traction

30

72.

An 18-year-old man with a 12-year history of type 1 diabetes mellitus comes to the physician for a follow-up
examination. Medications include 25 U of NPH insulin and 10 U of regular insulin in the morning and 10 U of NPH
insulin and 10 U of regular insulin before dinner. His hemoglobin A 1c was 14.5% 12 weeks ago. His current pulse is
80/min, respirations are 20/min, and blood pressure is 145/95 mm Hg. Examination shows scattered retinal
microaneurysms bilaterally. The remainder of the examination shows no other abnormalities. Laboratory studies
show:
Hemoglobin A1c
Serum
Na+
K+
Cl
HCO3
Glucose
Creatinine
Cholesterol
Urine
Blood
Glucose
Protein
Ketones

13%
130 mEq/L
3.2 mEq/L
101 mEq/L
23 mEq/L
325 mg/dL
1.5 mg/dL
350 mg/dL
negative
4+
1+
negative

Which of the following is the most likely renal diagnosis?


(A)
(B)
(C)
(D)
(E)

73.

Cholesterol renal emboli


Diabetic nephropathy
Hypertensive glomerulosclerosis
Hypokalemic nephropathy
Sodium-losing nephropathy

A hospitalized 57-year-old man has had severe progressive pain in his left knee since awakening 2 hours ago. He
was admitted to the hospital 2 days ago for an acute myocardial infarction. Cardiac catheterization showed occlusion
of the left anterior descending artery, and he underwent placement of a stent. Current medications include aspirin,
metoprolol, lisinopril, simvastatin, clopidogrel, and heparin. Vital signs are within normal limits. Examination of the
knee shows a large effusion. The knee is hot to touch and erythematous. He holds the knee in 30 degrees of flexion;
the pain is exacerbated with further flexion or extension. Laboratory studies show:
Hematocrit
Leukocyte count
Serum
Ca2+
Urea nitrogen
Creatinine
Albumin

40%
13,000/mm3
9.2 mg/dL
15 mg/dL
1.0 mg/dL
3.6 g/dL

An x-ray of the left knee shows calcification of the synovium. Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)

Deep venous thrombosis


Gonorrhea
Gout
Hemarthrosis
Pseudogout
Septic arthritis

31

74.

A 62-year-old white man comes to the physician because of an 8-month history of progressive pain and stiffness of
his hands. The stiffness is worse at the end of the day. He has a 1-year history of fatigue and increased urination. He
has no history of serious illness and takes no medications. His last visit to a physician was 10 years ago. He does not
smoke or drink alcohol. He is 185 cm (6 ft 1 in) tall and weighs 82 kg (180 lb); BMI is 24 kg/m 2. His pulse is
84/min, and blood pressure is 136/82 mm Hg. Examination shows dark brown skin. S 1 and S2 are normal. An S3 is
heard at the apex. There is mild tenderness over the second and third metacarpophalangeal joints bilaterally without
synovial thickening. Heberden nodes are present over the distal interphalangeal joints of the index and ring fingers
bilaterally. Laboratory studies show:
Hemoglobin
Leukocyte count
Platelet count
Serum
Glucose
Albumin
Total bilirubin
Alkaline phosphatase
AST
ALT
Hepatitis B surface antigen
Hepatitis C antibody
Rheumatoid factor

16 g/dL
7700/mm3
332,000/mm3
182 mg/dL
3.4 g/dL
1.1 mg/dL
52 U/L
55 U/L
68 U/L
negative
negative
negative

Which of the following is most likely to have prevented this patient's condition?
(A)
(B)
(C)
(D)
(E)

75.

Calcium supplementation
Enalapril therapy
Metformin therapy
Methotrexate therapy
Phlebotomy

A 52-year-old woman comes to the emergency department because of a 1-week history of low-grade fever and
increasing abdominal cramps that are exacerbated by bowel movements. She began a course of amoxicillinclavulanate and metronidazole 2 days ago but has had no relief of her symptoms. She has had intermittent
constipation for the past 12 years. She has not had nausea, vomiting, urinary symptoms, or bloody stools. She has a
3-year history of hypertension. She underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy 5
years ago because of leiomyomata uteri. She is 165 cm (5 ft 5 in) tall and weighs 86 kg (190 lb); BMI is 32 kg/m2.
Her temperature is 38.1C (100.6F), pulse is 75/min, and blood pressure is 150/80 mm Hg. The lungs are clear to
auscultation. Cardiac examination shows no abnormalities. The abdomen is soft, and there is tenderness to palpation
of the left lower quadrant with guarding but no rebound. Bowel sounds are normal. The stool is brown, and test for
occult blood is negative. Her hemoglobin concentration is 14.5 g/dL, leukocyte count is 15,000/mm 3, and platelet
count is 280,000/mm3; serum studies and urinalysis show no abnormalities. Which of the following is the most
appropriate next step in diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)

Examination of the stool for ova and parasites


Test of the stool for Clostridium difficile toxin
Endoscopic retrograde cholangiopancreatography
Pelvic ultrasonography
CT scan of the abdomen with contrast
Colonoscopy

32

76.

A previously healthy 32-year-old man is brought to the emergency department after being found unconscious on the
floor at his workplace. On arrival, he is obtunded. He is intubated and mechanical ventilation is begun. Examination
shows flaccid paralysis on the right. A CT scan of the head shows a large evolving cerebral infarction on the left.
Carotid duplex ultrasonography shows dissection of the left carotid artery. After receiving intensive medical care for
6 hours, the patient develops decerebrate posturing and becomes hemodynamically unstable. Vasopressor therapy is
begun. A second CT scan of the head shows a massive left hemispheric cerebral infarction with severe edema and
herniation. The physician determines that surgical intervention is not indicated because of the patient's poor
prognosis. The patient's driver's license indicates that he wishes to be an organ donor. The physician meets with the
patient's family and informs them about the patient's prognosis, and they are devastated. During the meeting, they
say that they were unaware of his willingness to be an organ donor and agree that he should not receive
cardiopulmonary resuscitation. Which of the following is the most appropriate next step with respect to organ
donation?
(A)
(B)
(C)
(D)

77.

Two days after admission to the hospital for congestive heart failure, an 82-year-old man is unable to walk because
of severe, throbbing pain in his left foot. He has no history of similar episodes or recent trauma. He also has
coronary artery disease and hypertension. Current medications include atenolol, lisinopril, furosemide, and aspirin.
He does not smoke or drink alcohol. He is in moderate distress. His temperature is 38C (100.4F), pulse is 68/min
and regular, respirations are 12/min, and blood pressure is 138/88 mm Hg. Jugular venous pulsations are present 3
cm above the sternal angle. Crackles are heard at both lung bases. A grade 2/6 systolic murmur is heard best at the
left sternal border and second intercostal space. Examination of the lower extremities shows pitting pedal edema.
There is tenderness, erythema, and edema of the left great toe. Active and passive range of motion of the first
metacarpophalangeal joint produces pain; arthrocentesis of the joint is performed. Analysis of joint fluid aspirate is
most likely to show which of the following?

(A)
(B)
(C)
(D)
(E)
(F)

78.

Arrange for the regional organ procurement organization to address the issue with the patient's family
Delay further consideration of the issue until after 24 hours of aggressive care
Delay further consideration of the issue until the family seems ready
Initiate organ donation at this time

WBC
(/mm3)
100
100
100
100
20,000
20,000

Microscopic Examination
for Crystals
needle-shaped
none
none
rhomboid
needle-shaped
none

Gram Stain
no organisms
gram-positive cocci
no organisms
no organisms
no organisms
gram-positive cocci

A 37-year-old woman with AIDS comes to the physician because of a 1-month history of progressive diarrhea and a
1.8-kg (4-lb) weight loss. During the past week, she has had six large watery stools daily. She is currently receiving
triple antiretroviral therapy. She is employed as a flight attendant and works regularly on domestic flights
throughout the USA. She also flies to Asia at least once monthly. She is 163 cm (5 ft 4 in) tall and weighs 59 kg
(130 lb); BMI is 22 kg/m2. Her temperature is 37C (98.6F), pulse is 88/min, and blood pressure is 112/64 mm Hg.
The abdomen is scaphoid. The remainder of the examination shows no abnormalities. Her CD4+ T-lymphocyte
count is 400/mm3 (Normal500). Which of the following is the most likely causal organism?
(A)
(B)
(C)
(D)
(E)

Cryptosporidium parvum
Cytomegalovirus
Mycobacterium avium-intracellulare complex
Salmonella enteritidis
Strongyloides stercoralis

33

79.

A 62-year-old man comes to the physician because of a 2-month history of progressive fatigue and ankle swelling.
He had an anterior myocardial infarction 3 years ago and has had shortness of breath with mild exertion since then.
Current medications include labetalol and daily aspirin. He has smoked one-half pack of cigarettes daily for 30
years. His pulse is 100/min and regular, respirations are 20/min, and blood pressure is 130/75 mm Hg. There are
jugular venous pulsations 5 cm above the sternal angle. Crackles are heard at both lung bases. Cardiac examination
shows an S3 gallop. There is edema from the midtibia to the ankle bilaterally. Further evaluation of this patient is
most likely to show which of the following findings?
(A)
(B)
(C)
(D)
(E)

80.

A 42-year-old woman comes to the physician because of a 1-year history of vaginal bleeding for 2 to 5 days every 2
weeks. The flow varies from light to heavy with passage of clots. Menses previously occurred at regular 25- to 29day intervals and lasted for 5 days with normal flow. She has no history of serious illness and takes no medications.
She is sexually active with one male partner, and they use condoms inconsistently. Her mother died of colon cancer,
and her maternal grandmother died of breast cancer. She is 163 cm (5 ft 4 in) tall and weighs 77 kg (170 lb); BMI is
29 kg/m2. Her temperature is 36.6C (97.8F), pulse is 90/min, respirations are 12/min, and blood pressure is 100/60
mm Hg. The uterus is normal sized. The ovaries cannot be palpated. The remainder of the examination shows no
abnormalities. Test of the stool for occult blood is negative. Which of the following is the most appropriate next step
in diagnosis?
(A)
(B)
(C)
(D)
(E)

81.

Barium enema
Progesterone challenge test
Colposcopy
Cystoscopy
Endometrial biopsy

A 42-year-old woman is brought to the emergency department 10 minutes after being involved in a highspeed motor vehicle collision in which she was a restrained passenger. On arrival, she has shortness of breath and
abdominal pain. Her pulse is 135/min, respirations are 30/min, and blood pressure is 80/40 mm Hg. Breath sounds
are decreased at the left lung base. An x-ray of the chest shows opacification of the left lower lung field with loss of
the diaphragmatic shadow. Placement of a chest tube yields a small amount of air followed by greenish fluid. Which
of the following is the most appropriate next step in management?
(A)
(B)
(C)
(D)
(E)

82.

Decreased pulmonary capillary wedge pressure


Impaired contractility of the left ventricle
Prolapse of the mitral valve
Thrombosis of the superior vena cava
Ventricular septal defect

CT scan of the abdomen


CT scan of the chest
Thoracoscopy
Laparotomy
Thoracotomy

A 5-year-old boy is brought to the physician by his mother because of a 2-day history of a low-grade fever, cough,
and runny nose. His temperature is 38C (100.4F). Examination findings are consistent with a diagnosis of a
common cold. The physician refers to a randomized, double-blind, placebo-controlled clinical trial that evaluated the
effectiveness of a new drug for the treatment of the common cold. The mean time for resolution of symptoms for
patients receiving the new drug was 6.4 days, compared with a mean time of 6.7 days for patients receiving the
placebo (p=0.04). Which of the following is the most appropriate interpretation of these study results?
(A)
(B)
(C)
(D)

The findings are clinically and statistically significant


The findings are clinically insignificant but statistically significant
The findings are clinically significant but statistically insignificant
The findings are neither clinically nor statistically significant

34

83.

A 77-year-old man is brought to the physician because of a 12-hour history of word-finding difficulty and weakness
and sensory loss of the right arm and leg. He has no history of similar symptoms. He has type 2 diabetes mellitus,
hypertension, and atrial fibrillation. Current medications include metformin, lisinopril, and aspirin. He is alert. His
pulse is 80/min and irregular, respirations are 16/min, and blood pressure is 170/90 mm Hg. He follows commands
but has nonfluent aphasia. There is moderate weakness and decreased sensation of the right upper and lower
extremities. Deep tendon reflexes are 2+ bilaterally. Babinski sign is present on the right. His serum glucose
concentration is 162 mg/dL. Which of the following is the most appropriate next step in diagnosis?
(A)
(B)
(C)
(D)
(E)

84.

Carotid duplex ultrasonography


CT scan of the head
EEG
Lumbar puncture
Cerebral angiography

A 19-year-old man is brought to the emergency department by a friend because of strange behavior during the past 2
hours at a party. The patient has seemed confused and has been insisting that someone is following him. On arrival,
he is alert but confused. He says that he is angry because his friend had promised that the ride to the hospital would
only take 5 minutes, but it seemed to take several hours. He states that he has been hungry all evening, and he asks if
there is anywhere he can get something to eat. He is dressed casually in baggy pants and a T-shirt. His temperature
is 37.2C (99F), pulse is 107/min, respirations are 12/min, and blood pressure is 120/85 mm Hg. Examination
shows injected conjunctivae. Deep tendon reflexes are decreased. There is ataxia on finger-nose testing. On mental
status examination, he has a mildly anxious affect. His speech is slow, and his thought process is disorganized. He
looks out the door of the examination room frequently during the examination. Which of the following is the most
likely cause of these findings?
(A)
(B)
(C)
(D)
(E)
(F)
(G)

Alcohol
Heroin
Inhalant
LSD
Marijuana
Methamphetamine
PCP (phencyclidine)

35

The response options for the next 2 items are the same. Select one answer for each item in the set.
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(I)
(J)
(K)
(L)
(M)
(N)
(O)

Acute bacterial urethritis


Acute cystitis
Atrophic vaginitis
Bacterial vaginosis
Candidal vaginitis
Carcinoma of the bladder
Chemical urethritis
Chlamydial urethritis
Distal ureteral calculus
Gonorrheal urethritis
Herpes urethritis
Interstitial cystitis
Pyelonephritis, acute
Pyelonephritis, subclinical
Trichomonal vaginitis

For each patient with pain or burning with urination, select the most likely diagnosis.
85.

A previously healthy 37-year-old woman comes to the physician because of a 2-day history of urinary frequency and
urgency and burning with urination. This morning, she noticed some blood in her urine. Her last menstrual period
was 3 weeks ago, and she has no abnormal vaginal discharge. She is in a monogamous relationship, and her partner
has no similar symptoms. Her temperature is 37.2C (99F), pulse is 78/min, respirations are 12/min, and blood
pressure is 120/82 mm Hg. Examination shows suprapubic tenderness to palpation without masses, guarding, or
rebound. There is no costovertebral angle tenderness. Urine dipstick shows 1+ leukocyte esterase, 2+ blood, and no
nitrites.

86.

A previously healthy 32-year-old woman comes to the physician because of a 2-week history of episodic burning
with urination without urinary hesitancy or urgency. She discontinued an oral contraceptive 4 months ago because of
weight gain and now uses condoms and spermicidal jelly. She is in a monogamous relationship. Her temperature is
36.6C (97.8F), pulse is 78/min, and blood pressure is 118/60 mm Hg. There is no costovertebral angle tenderness.
Abdominal examination shows no abnormalities. Pelvic examination shows vaginal erythema and scant mucoid
discharge. There is no cervical motion tenderness or adnexal masses. Urine dipstick shows no leukocyte esterase,
nitrites, or blood. KOH preparation, wet mount preparation, and testing for Neisseria gonorrhoeae and Chlamydia
trachomatis are negative.

36

Sample Questions
Block 3 (Questions 87-131)
87.

A 19-year-old man comes to the physician because of a 3-week history of malaise, generalized fatigue, swelling of
his legs, and dark urine. He has no known sick contacts. There is no personal or family history of serious illness. He
takes no medications. His temperature is 37C (98.6F), pulse is 82/min, respirations are 14/min, and blood pressure
is 152/91 mm Hg. Examination shows 2+ pretibial edema bilaterally. The remainder of the examination shows no
abnormalities. Laboratory studies show:
Hemoglobin
Leukocyte count
Platelet count
Serum
Na+
K+
Cl
HCO3
Urea nitrogen
Creatinine
Urine
Blood
Protein
RBC
RBC casts

10.4 g/dL
5000/mm3
250,000/mm3
135 mEq/L
4.9 mEq/L
101 mEq/L
19 mEq/L
68 mg/dL
4.6 mg/dL
3+
3+
57/hpf with dysmorphic features
numerous

Serum complement concentrations are within the reference ranges. Renal ultrasonography shows no abnormalities.
A renal biopsy specimen shows a crescent formation in the glomeruli and immune complex deposition along the
basement membrane. The most appropriate next step in management is administration of which of the following?
(A)
(B)
(C)
(D)
(E)

88.

Oral azathioprine
Oral lisinopril
Intravenous fluids
Intravenous furosemide
Intravenous methylprednisolone

A 5-year-old girl is brought to the physician by her parents for evaluation of recurrent injuries. Her parents say that
she started walking at the age of 14 months and since then has always seemed clumsier and had more injuries than
other children. She has had increasingly frequent chest pain with exertion since starting a soccer program 3 months
ago. She usually has pain or swelling of her knees or ankles after practice. She has been wearing glasses for 2 years.
Her 16-year-old brother has required two operations for a severe rotator cuff injury he sustained while taking a
shower, and she has a maternal cousin who died of a ruptured aortic aneurysm at the age of 26 years. Today, the
patient walks with a limp. She is at the 99th percentile for height and 50th percentile for weight. A midsystolic click
is heard at the apex. The left ankle is swollen and tender; range of motion is limited by pain. The joints of the upper
and lower extremities are hypermobile, including 25 degrees of genu recurvatum, thumbs that may be extended to
touch the forearms, and flexibility at the waist, with palms easily touching the floor with straight knees. Which of
the following is the most appropriate next step in diagnosis?
(A)
(B)
(C)
(D)
(E)

Skeletal survey
Echocardiography
Bone scan
MRI of the shoulder
Aortic angiography

37

89.

A 4-year-old boy with asthma becomes limp during treatment with inhaled albuterol in the emergency department.
Ten minutes ago, he received intravenous methylprednisolone for an acute exacerbation, and he was alert and
oriented at that time. He received the diagnosis of asthma 2 years ago and has been admitted to the hospital for acute
exacerbations eight times since then. Current medications include albuterol and montelukast. He appears pale and
gasps and moans as he attempts to breathe. He responds to voice. His temperature is 36C (96.8F), pulse is 160/min
and thready, respirations are 18/min, and blood pressure is 50/20 mm Hg. The skin is cold to the touch. Pulmonary
examination shows poor air movement, especially on the left. No wheezes are heard. The point of maximal impulse
is 2 cm to the left of the midclavicular line in the sixth intercostal space. A chest x-ray is shown. Which of the
following is the most likely underlying cause of this patient's hypotension?
(A)
(B)
(C)
(D)
(E)

90.

Adverse effect of albuterol


Adverse effect of methylprednisolone
Atelectasis of the left lung
Decrease in cardiac output
Severe bronchospasm

A 17-year-old girl comes to the physician for an examination prior to entering college. She reports that she feels
well but is nervous about leaving home for the first time. She states that she has tried to diet to improve her
appearance but that food restriction often "backfires" because she becomes hungry and then engages in episodes of
binge eating. She reports a loss of control during these episodes, saying "It's like I stop thinking at all and before I
know it, I have eaten two pizzas." She induces vomiting several times during each binge and has developed a pattern
of binging and purging every evening. She has no history of serious illness and takes no medications. She is 165 cm
(5 ft 5 in) tall and weighs 57 kg (125 lb); BMI is 21 kg/m 2. Vital signs are within normal limits. Physical
examination shows dry mucous membranes, erosion of enamel on the lingual surface of the front teeth, and
hypertrophy of the parotid gland. Serum studies are most likely to show which of the following sets of findings in
this patient?

(A)
(B)
(C)
(D)
(E)
(F)

Potassium
Decreased
Decreased
Increased
Increased
Normal
Normal

Bicarbonate
decreased
increased
decreased
increased
decreased
increased

38

91.

A previously healthy 18-year-old man is brought to the emergency department because of abdominal pain and
nausea for 6 hours. He has had decreased appetite for the past week. He takes no medications. He drinks one to two
beers daily and occasionally more on weekends. He does not use illicit drugs. His temperature is 37.8C (100F),
pulse is 120/min, respirations are 24/min, and blood pressure is 105/60 mm Hg. Abdominal examination shows
diffuse tenderness with no guarding or rebound. Bowel sounds are normal. Laboratory studies show:
Serum
Na+
Cl
K+
HCO3
Glucose
Ketones
Urine ketones

135 mEq/L
98 mEq/L
3.8 mEq/L
16 mEq/L
360 mg/dL
present
present

Arterial blood gas analysis on room air shows a pH of 7.30. Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)

92.

A 4-year-old boy with a displaced supracondylar fracture of the humerus without neurovascular complication is
placed in skeletal traction. Six hours later, he has severe pain in the forearm and increased pain on passive extension
of the wrist and fingers. Which of the following is the most appropriate next step in management?
(A)
(B)
(C)
(D)
(E)

93.

Acute appendicitis
Acute pancreatitis
Alcoholic ketoacidosis
Diabetic ketoacidosis
Lactic acidosis

Increased weight on the traction apparatus


Administration of analgesic medication
Exploration of the fracture and fasciotomy of the flexor compartment of the forearm
Closed reduction with the patient under anesthesia
Open reduction and internal fixation of the fracture

A 70-year-old man comes to the physician because of fever, productive cough, and pleuritic chest pain for 1 day.
Over the past 2 years, he has had two similar episodes. He also has had persistent pain in the thoracic spine for 1
month. His temperature is 39.2C (102.6F), pulse is 94/min, respirations are 22/min, and blood pressure is 110/60
mm Hg. There is dullness to percussion and decreased breath sounds over the right base. Examination shows
tenderness of the midthoracic spine. Laboratory studies show:
Hematocrit
Leukocyte count
Segmented neutrophils
Bands
Lymphocytes
Serum calcium

34%
15,000/mm3
81%
4%
15%
10.9 mg/dL

X-rays of the chest show consolidation of the right lower lobe, lytic lesions at T8 and T10, and diffuse osteopenia.
Which of the following is the most likely diagnosis of this patient's back condition?
(A)
(B)
(C)
(D)
(E)

HIV infection
Multiple myeloma
Prostate cancer
Staphylococcal osteomyelitis
Tuberculosis osteomyelitis

39

94.

A 6-year-old girl is brought to the physician because of a 1-month history of a recurrent pruritic rash on her arms.
She was born at term and has been healthy except for an episode of bronchiolitis 6 months ago treated with
albuterol. A photograph of the rash is shown. Which of the following is the most appropriate next step in
management?
(A)
(B)
(C)
(D)
(E)

95.

A 67-year-old woman comes to the physician because of dizziness for 6 weeks. When she stands up suddenly, she
becomes light-headed and has to steady herself for approximately 1 to 2 minutes before she is able to walk. She has
hypertension and type 2 diabetes mellitus. Current medications include glyburide, a diuretic, a -adrenergic blocking
agent, and an angiotensin-converting enzyme (ACE) inhibitor. Her pulse is 55/min. Her blood pressure is
110/70 mm Hg in the right arm and 70/50 mm Hg in the left arm while supine; her blood pressure is 70/50 mm Hg
in the right arm and 50/30 mm Hg in the left arm immediately after standing. Neurologic examination shows no
focal findings. An ECG shows sinus bradycardia with no evidence of ischemia. Carotid duplex ultrasonography
shows reverse flow in the left vertebral artery with no evidence of occlusion. Which of the following is the most
appropriate next step in management?
(A)
(B)
(C)
(D)
(E)

96.

Coal tar therapy


Oral antibiotic therapy
Topical antibiotic therapy
Topical corticosteroid therapy
Vitamin supplementation

Cardiac stress scintigraphy


Adjusting her medication regimen
Warfarin therapy
Transesophageal echocardiography
Coronary arteriography

A 9-month-old boy is brought to the physician because of discharge from the left ear for 1 day. He has had frequent
infections since the age of 4 months. He had Streptococcus pneumoniae bacteremia at 4 months of age,
Haemophilus influenzae meningitis at 5 months of age, and S. pneumoniae pneumonia at 7 months of age. He also
has had two episodes of otitis media during this period. He is an only child, and there is no family history of
frequent infections. His immunizations are up-to-date. He is at the 20th percentile for length and 3rd percentile for
weight. He is not in acute distress. Examination shows no abnormalities other than a purulent drainage from the left
ear canal. Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)

Chronic granulomatous disease of childhood


Severe combined immunodeficiency
Thymic-parathyroid dysplasia (DiGeorge syndrome)
Transient hypogammaglobulinemia of infancy
X-linked agammaglobulinemia

40

97.

A 67-year-old man is brought to the emergency department because of a 1-week history of nausea, generalized
weakness, and malaise. He has congestive heart failure, hypertension, and coronary artery disease. Current
medications include lisinopril, digoxin, isosorbide, spironolactone, and metoprolol. His temperature is 37.2C
(99F), pulse is 88/min, and blood pressure is 140/90 mm Hg. Examination shows a soft abdomen. There is
2+ edema in the lower extremities. Laboratory studies show:
Hematocrit
Leukocyte count
Serum
Na+
K+
HCO3
Urea nitrogen
Creatinine
AST

36%
10,000/mm3
140 mEq/L
7.3 mEq/L
18 mEq/L
40 mg/dL
1.8 mg/dL
20 U/L

Urinalysis shows no abnormalities. Which of the following is the most likely explanation for this patient's
hyperkalemia?
(A)
(B)
(C)
(D)
(E)

98.

A 52-year-old man comes to the physician with his wife because of a 1-year history of excessive daytime sleepiness.
He does not think the symptoms are problematic, but his wife is concerned because he sometimes falls asleep on the
sofa early in the evening when guests are present. He also once fell asleep while driving at night and drove off the
road, narrowly avoiding injury. His wife says that he has always snored loudly, and over the past year, he has had
episodes of choking or gasping for breath while sleeping. He is 178 cm (5 ft 10 in) tall and weighs 105 kg (231 lb);
BMI is 33 kg/m2. His pulse is 76/min, respirations are 14/min, and blood pressure is 150/76 mm Hg. Physical and
neurologic examinations show no other abnormalities. Which of the following is most likely to confirm the
diagnosis?
(A)
(B)
(C)
(D)
(E)

99.

Adverse effect of medications


Laboratory error
Metabolic acidosis
Renal failure
Rhabdomyolysis

24-Hour ambulatory ECG monitoring


Multiple sleep latency test
Polysomnography
CT scan of the head
Laryngoscopy

A 67-year-old woman has had fatigue, dry skin, brittle hair, swelling of the ankles, and cold intolerance for 1 year;
she has gained 9 kg (20 lb) during this period. Her pulse is 55/min, and blood pressure is 150/90 mm Hg. She
appears lethargic. Examination shows dry skin and a nontender thyroid gland that is enlarged to two times its normal
size. There is mild edema of the ankles bilaterally. The relaxation phase of the Achilles reflex is greatly prolonged.
Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)

Chronic lymphocytic thyroiditis (Hashimoto disease)


Defect in thyroxine (T4) biosynthesis
Graves disease
Multinodular goiter
Riedel thyroiditis
Thyroid cyst
Thyroid lymphoma
Thyroiditis

41

100.

A 62-year-old woman comes to the physician because of a 3-day history of a rash over her face and hands that has
not improved with the use of skin moisturizers, antibiotic ointments, or corticosteroid cream. She has a 1month history of progressive weakness. She has difficulty rising from a chair or reaching over her head. She has not
had any pain. Vital signs are within normal limits. A photograph of the hands is shown. Muscle strength is 3/5 in the
proximal upper and lower extremities. Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)

101.

A previously healthy 17-year-old girl comes to the emergency department because of a 5-day history of progressive
lower abdominal pain, fever, and malodorous vaginal discharge. Menarche was at the age of 12 years, and her last
menstrual period was 2 weeks ago. She is sexually active with one male partner and uses a combination
contraceptive patch. Her temperature is 37.8C (100F), pulse is 90/min, respirations are 22/min, and blood pressure
is 110/70 mm Hg. Abdominal examination shows severe lower quadrant tenderness bilaterally. Pelvic examination
shows a purulent cervical discharge, cervical motion tenderness, and bilateral adnexal tenderness. Her hemoglobin
concentration is 10.5 g/dL, leukocyte count is 13,000/mm3, and platelet count is 345,000/mm3. A urine pregnancy
test is negative. Which of the following is the most appropriate pharmacotherapy?
(A)
(B)
(C)
(D)
(E)

102.

Dermatomyositis
Myasthenia gravis
Psoriasis
Systemic lupus erythematosus
Systemic sclerosis (scleroderma)

Oral azithromycin
Vaginal clindamycin
Intravenous penicillin and vancomycin
Intramuscular ceftriaxone and oral doxycycline
Intravenous oxacillin and metronidazole

A 27-year-old nurse comes to the emergency department because of nervousness, dizziness, palpitations, and excess
perspiration for the past 3 hours. She has had similar episodes over the past 6 months. The symptoms improve
following ingestion of orange juice or soft drinks. She says that she has had a great deal of stress. She has been
drinking two alcoholic beverages daily for the past month; before this time, she seldom drank alcohol. Examination
shows no abnormalities. Her serum glucose concentration is 30 mg/dL. Intravenous glucose is administered, and the
patient's symptoms improve. Which of the following is the most appropriate next step in diagnosis?
(A)
(B)
(C)
(D)
(E)

Liver tests
Measurement of serum proinsulin and insulin antibodies
Measurement of serum cortisol and ACTH concentrations
Measurement of serum growth hormone and plasma somatomedin-C concentrations
Measurement of serum insulin and C-peptide concentrations

42

103.

A 62-year-old man comes to the physician because of a 3-month history of progressive fatigue and joint pain, a 2month history of sinus congestion, a 3-week history of cough, and a 1-week history of blood-tinged sputum. He has
not had fever, nausea, vomiting, or diarrhea. He has hypercholesterolemia, stable angina pectoris, and hypertension.
Medications include atorvastatin, labetalol, isosorbide, and aspirin. Over the past 3 weeks, he has been taking overthe-counter ibuprofen as needed for the joint pain. His pulse is 84/min, respirations are 12/min, and blood pressure is
132/76 mm Hg. Examination shows clear nasal discharge with no nasal or oral lesions. The joints are diffusely
tender with no warmth or erythema; range of motion is full. Laboratory studies show:
Hematocrit
Mean corpuscular volume
Leukocyte count
Segmented neutrophils
Eosinophils
Lymphocytes
Monocytes
Platelet count
Serum
Urea nitrogen
Creatinine
Antinuclear antibodies
Rheumatoid factor
Antineutrophil cytoplasmic antibodies
Urine
Blood
Protein
RBC
WBC
RBC casts

36%
83 m3
14,000/mm3
74%
1%
14%
11%
275,000/mm3
28 mg/dL
3.2 mg/dL
1:256
negative
positive
3+
3+
1517/hpf
12/hpf
rare

Which of the following is the most likely underlying mechanism of this patient's renal failure?
(A)
(B)
(C)
(D)
(E)
(F)

104.

Atheroembolic disease
Cold agglutinins
Interstitial nephritis
Lyme disease
Septic arthritis
Vasculitis

A 32-year-old man comes to the physician because he has had difficulty focusing on tasks at work and at home
during the past 2 months. He works as an automobile mechanic. He has had a lot of energy for work but often is
distracted to the point that he does not complete assigned tasks. He frequently stops working on his own tasks to
attempt to develop greater efficiency in his shop. He states that he is delighted with his newfound energy and reports
that he now needs only 4 hours of sleep nightly. He has no history of psychiatric illness. He always performed well
in school. He has a history of drinking alcohol excessively and using methamphetamines and cocaine during his 20s,
but he has not consumed alcohol or used illicit drugs for the past 3 years. His temperature is 37C (98.6F), pulse is
60/min, and blood pressure is 125/80 mm Hg. Physical examination shows no abnormalities. On mental status
examination, he describes his mood as "good." He has a labile affect. His speech is rapid in rate but normal in
rhythm, and his thought process is organized. Short- and long-term memory are intact. Attention and concentration
are fair; he makes no errors when performing serial sevens, and he can repeat seven digits forward and five in
reverse sequence. He has had no delusions or hallucinations. Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)

Antisocial personality disorder


Attention-deficit/hyperactivity disorder
Bipolar disorder
Borderline personality disorder
Major depressive disorder

43

105.

A 56-year-old man has had the painful weeping rash shown for 2 days. He underwent chemotherapy for nonHodgkin lymphoma 1 year ago. His temperature is 36.7C (98F), pulse is 80/min, and blood pressure is
138/76 mm Hg. Examination shows no other abnormalities. Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)

106.

Herpes zoster
Impetigo
Pyoderma gangrenosum
Syphilis
Systemic lupus erythematosus

A 15-year-old boy is brought to the physician because of fatigue since starting his freshman year of high school
3 months ago. He often falls asleep during class. He urinates four to five times nightly and often has difficulty
falling asleep again. He has no history of serious illness and takes no medications. He is at the 20th percentile for
height and above the 95th percentile for weight and BMI. Vital signs are within normal limits. Examination shows a
velvety, hyperpigmented, macular rash over the neck and axillae. The remainder of the examination shows no
abnormalities. Results of a complete blood count and serum electrolyte concentrations show no abnormalities.
Additional laboratory studies show:
Serum glucose
Urine
pH
Specific gravity
Glucose
Ketones

134 mg/dL
5.5
1.028
1+
negative

In addition to dietary counseling, which of the following is the most appropriate initial treatment?
(A)
(B)
(C)
(D)
(E)

Exercise program
Increased fluid intake
Cyclosporine therapy
Insulin therapy
Oral hypoglycemic agent

44

107.

A previously healthy 47-year-old man comes to the physician because of a 6.8-kg (15-lb) weight loss over the past 6
months. He spent 2 weeks in Mexico 3 months ago. Since returning, he has noticed that his stools have changed in
size and consistency. He has not had fever, night sweats, or change in appetite. He takes no medications. He has
smoked one pack of cigarettes daily for 20 years. He appears healthy and well nourished. His temperature is 37C
(98.6F), pulse is 105/min, respirations are 16/min, and blood pressure is 130/78 mm Hg. Examination shows pale
conjunctivae. The abdomen is soft with no organomegaly. Rectal examination shows a normal prostate with no
masses. Test of the stool for occult blood is positive. Laboratory studies show:
Hemoglobin
Mean corpuscular volume
Platelet count
Red cell distribution width

11 g/dL
72 m3
300,000/mm3
16% (N=13%15%)

Which of the following is the most appropriate next step in diagnosis?


(A)
(B)
(C)
(D)
(E)

108.

A 19-year-old woman noticed a mass in her left breast 2 weeks ago while doing monthly breast self-examination.
Her mother died of metastatic breast cancer at the age of 40 years. Examination shows large dense breasts; a 2-cm,
firm, mobile mass is palpated in the upper outer quadrant of the left breast. There are no changes in the skin or
nipple, and there is no palpable axillary adenopathy. Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)

109.

Second complete blood count in 3 months


CT scan of the abdomen
Colonoscopy
Esophagogastroduodenoscopy
Sigmoidoscopy

Fibroadenoma
Fibrocystic changes of the breast
Infiltrating ductal carcinoma
Intraductal papilloma
Lobular carcinoma

A 32-year-old woman comes to the physician because of fatigue for 6 months. She has had progressively severe
dyspnea on exertion for 6 weeks. She had an extensive abdominal operation 5 years ago for Crohn disease. She does
not take any medications. Her temperature is 37C (98.6F), pulse is 62/min, respirations are 18/min, and blood
pressure is 110/65 mm Hg. Examination of the thyroid gland, lungs, heart, abdomen, and extremities shows no
abnormalities. Test of the stool for occult blood is negative. Laboratory studies show:
Hemoglobin
Mean corpuscular volume
Leukocyte count
Platelet count

8 g/dL
70 m3
9000/mm3
500,000/mm3

Which of the following is the most likely diagnosis?


(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)

Acute leukemia
Anemia of chronic disease
Folic acid deficiency
Iron deficiency
Lyme disease
Microangiopathic hemolytic anemia
Pernicious anemia
Sleep apnea

45

110.

Three days after hospitalization for diabetic ketoacidosis, an 87-year-old woman refuses insulin injections. She says
that her medical condition has declined so much that she no longer wishes to go on living; she is nearly blind and
will likely require bilateral leg amputations. She reports that she has always been an active person and does not see
how her life will be of value anymore. She has no family and most of her friends are sick or deceased. On mental
status examination, she is alert and cooperative. She accurately describes her medical history and understands the
consequences of refusing insulin. There is no evidence of depression. She dismisses any attempts by the physician to
change her mind, saying that the physician is too young to understand her situation. She says, "I know I will die, and
this is what I want." Which of the following is the most appropriate next step in management?
(A)
(B)
(C)
(D)
(E)

111.

Discharge the patient after she has signed an "against medical advice" form
Seek a court order to appoint a legal guardian
Offer insulin but allow the patient to refuse it
Admit to the psychiatric unit
Administer insulin against the patient's wishes

A 72-year-old woman with unresectable small cell carcinoma of the lung is brought to the emergency department
after her family found her unresponsive. During the past week, she has become progressively confused. On arrival,
she does not respond to command but withdraws all extremities to pain. Her temperature is 37C (98.6F), pulse is
80/min, respirations are 12/min, and blood pressure is 130/70 mm Hg. The pupils are equal and reactive to light, and
corneal reflexes are brisk; there is spontaneous medial and lateral gaze. Laboratory studies show:
Hemoglobin
Leukocyte count
Serum
Na+
Cl
K+
HCO3
Urea nitrogen
Glucose
Creatinine

12.2 g/dL
6000/mm3
118 mEq/L
98 mEq/L
4.5 mEq/L
26 mEq/L
16 mg/dL
95 mg/dL
0.8 mg/dL

Which of the following is the most likely mechanism of these findings?


(A)
(B)
(C)
(D)
(E)
(F)
(G)

112.

Adrenal insufficiency
Inadequate renal blood flow
Injury to the renal tubules
Nonphysiologic ADH (vasopressin) secretion
Nonphysiologic aldosterone secretion
Physiologic ADH (vasopressin) secretion
Physiologic aldosterone secretion

A 19-year-old college student comes to the physician because of vaginal irritation and pain with urination for 5 days.
Two weeks ago, she had streptococcal pharyngitis treated with amoxicillin. She has been sexually active with two
partners over the past year; she uses condoms for contraception. Her last menstrual period was 1 week ago. Her
temperature is 37.2C (99F), and blood pressure is 90/60 mm Hg. Pelvic examination shows erythema of the vulva
and vagina and a thick white vaginal discharge. The pH of the discharge is 4. Which of the following is the most
likely cause of these findings?
(A)
(B)
(C)
(D)
(E)
(F)

Bacterial vaginosis
Candidiasis
Chlamydia trachomatis infection
Escherichia coli infection
Neisseria gonorrhoeae infection
Trichomoniasis

46

113.

A 67-year-old man is brought to the emergency department because of headache and decreased level of
consciousness over the past hour. He has a 20-year history of poorly controlled hypertension. He is unresponsive to
verbal stimuli. With painful stimulation, he moves the left extremities semipurposely but not the right extremities.
The left pupil is larger than the right and reacts sluggishly to light. Babinski sign is present on the right. A CT scan
of the head shows a large hyperintense mass in the left basal ganglia with compression of the left lateral ventricle
and shift of the midline structures. Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(I)
(J)
(K)
(L)
(M)
(N)
(O)
(P)
(Q)

114.

A 10-year-old boy is brought for a follow-up examination 2 days after he was seen in the emergency department
because of hives, hoarseness, and light-headedness. His symptoms began 15 minutes after he was stung by a bee and
lasted approximately 60 minutes; they resolved before he was treated. He has been stung by bees three times over
the past year, and each reaction has been more severe. Examination shows no abnormalities. Which of the following
is the most appropriate recommendation to prevent future morbidity and mortality from this condition?
(A)
(B)
(C)
(D)
(E)

115.

Acute cerebral infarction


Arteriovenous malformation
Astrocytoma
Bacterial abscess
Carotid cavernous fistula
Epidural abscess
Epidural hematoma
Fungal abscess
Glioblastoma multiforme
Intracerebral hemorrhage
Medulloblastoma
Meningioma
Metastatic carcinoma
Mycobacterium avium-intracellulare granuloma
Sturge-Weber syndrome
Subarachnoid hemorrhage
Subdural hematoma

Avoid areas known to have bees


Avoid wearing colorful clothing outside
Carrying diphenhydramine tablets
Carrying self-injectable epinephrine
Seek immediate medical attention following any future sting

A 67-year-old man with chronic cough comes to the emergency department after he coughed up 1 cup of bright red
blood this morning. He has a 3-week history of increasingly severe cough productive of whitish yellow sputum and
a 1-week history of fever. Over the past 3 days, the sputum has contained small amounts of blood. He has not had
chest pain. He has type 2 diabetes mellitus and hypertension. He has a 40-year history of alcoholism and drinks eight
alcoholic beverages daily. He had tuberculosis 15 years ago treated for 1 year with isoniazid and rifampin. His
temperature is 37.8C (100F), pulse is 108/min, respirations are 22/min, and blood pressure is 130/84 mm Hg.
Scattered rhonchi are heard that move with coughing; there are no wheezes. Cardiac examination shows a normal
rhythm and no murmurs or gallops. There is trace pedal edema bilaterally. An x-ray of the chest shows a single
cavitary lesion. A CT scan of the chest shows a soft tissue mass within the cavity. Which of the following is the
most likely diagnosis?
(A)
(B)
(C)
(D)
(E)

Aspergilloma
Bacterial lung abscess
Bronchogenic carcinoma
Histoplasmosis
Tuberculosis

47

116.

A 57-year-old woman comes to the physician because of a worsening cough productive of yellow sputum over the
past 3 days. She has a 2-year history of shortness of breath with exertion and chronic cough productive of white
sputum daily but has no history of pneumonia or other pulmonary problems. She has a 20-year history of
hypertension. Current medications include hydrochlorothiazide (25 mg daily) and an ipratropium inhaler (four puffs
four times daily). She has smoked one-half pack of cigarettes daily for 37 years. Her temperature is 37C (98.6F),
pulse is 80/min, respirations are 16/min, and blood pressure is 120/76 mm Hg. Examination shows an increased
anteroposterior diameter. Occasional expiratory wheezes are heard. S 1 and S2 are normal, and an S4 is heard; the
point of maximal impulse is subxiphoid. An x-ray of the chest shows flat diaphragms and a midline cardiac
silhouette. Which of the following is the most appropriate next step in management?
(A)
(B)
(C)
(D)
(E)

117.

A 27-year-old woman, gravida 2, para 1, at 10 weeks' gestation comes to the physician for a routine prenatal visit.
She is concerned about the risk for Down syndrome in her fetus because her first child has Down syndrome. She
would like to be tested as soon as possible. There is no personal or other family history of serious illness.
Examination shows a uterus consistent in size with a 10-week gestation. Which of the following is the most
appropriate diagnostic test for this syndrome in this patient at this time?
(A)
(B)
(C)
(D)
(E)

118.

Measurement of fetal nuchal fold


Measurement of maternal serum -fetoprotein concentration
Chorionic villus sampling
Amniocentesis
Cordocentesis

A 32-year-old woman, gravida 3, para 2, at 41 weeks' gestation is admitted to the hospital in active labor. Pregnancy
has been complicated by mild asthma treated with inhaled bronchodilators. At the beginning of the second stage of
labor, the cervix is 100% effaced and 10 cm dilated; the vertex is at -1 station. The fetal heart rate is reactive with no
decelerations. After 10 minutes of pushing, there is a prolonged deceleration to 60/min. The patient has the acute
onset of shortness of breath, rapidly develops cyanosis, and becomes unresponsive. Her pulse and blood pressure
cannot be detected. Immediate resuscitation is started. Five minutes later, there is bleeding from the nose, mouth,
and intravenous sites. Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)
(E)

119.

Perform incentive spirometry


Begin oral antibiotic therapy
Begin oral theophylline therapy
Increase hydrochlorothiazide dosage
Switch from hydrochlorothiazide to furosemide therapy

Amniotic fluid embolism


Intracerebral hemorrhage
Myocardial infarction
Status asmaticus
Toxic shock syndrome

A 46-year-old man comes to the physician because of intermittent lower abdominal pain over the past 3 months.
There is no family history of cancer. Examination shows no other abnormalities. His hematocrit is 38%. Test of the
stool for occult blood is positive. Colon contrast studies show a 1.5-cm polyp in the descending colon. An upper
gastrointestinal series shows no abnormalities. Which of the following is the most appropriate next step in
management?
(A)
(B)
(C)
(D)
(E)

CT scan of abdomen
Repeat test of the stool for occult blood after 3 days on a meat-free diet
Measurement of serum carcinoembryonic antigen (CEA) concentration
Colonoscopy with polypectomy
Total colectomy

48

120.

A 57-year-old woman is brought to the emergency department 45 minutes after she fell after an episode of lightheadedness. She has a 6-month history of progressive fatigue, tingling sensations in her fingers and toes, and loss of
balance. She underwent a partial gastrectomy for peptic ulcer disease 10 years ago. She has type 2 diabetes mellitus.
She has smoked one pack of cigarettes daily for 40 years. Her only medication is insulin. She appears pale. Her
temperature is 37C (98.6F), pulse is 105/min, respirations are 20/min, and blood pressure is 124/76 mm Hg. The
abdomen is soft with a well-healed surgical scar. Sensation to vibration and position is absent over the upper and
lower extremities. She has a broad-based gait. Laboratory studies show:
Hemoglobin
Mean corpuscular volume
Leukocyte count
Platelet count
Serum
Bilirubin, total
Direct
Lactate dehydrogenase

8.3 g/dL
105 m3
4800/mm3
100,000/mm3
2.1 mg/dL
0.2 mg/dL
320 U/L

Which of the following is the most likely explanation for these findings?
(A)
(B)
(C)
(D)
(E)
(F)

121.

A 6-year-old boy is brought to the emergency department 2 hours after injuring his arm when he fell out of a tree.
His mother says that he is extremely active and likes to climb. During the past year, he fractured his right tibia after
falling off a trampoline and sustained a concussion after falling off his bicycle. She says that his teachers reprimand
him frequently for running wildly in the classroom, talking excessively, and getting out of his seat; he often forgets
to turn in his homework. His parents are currently divorcing. His father has a history of illicit drug use. The patient
is at the 50th percentile for height and weight. His pulse is 80/min, and blood pressure is 100/80 mm Hg. Physical
examination shows a dislocated left shoulder, healing abrasions over the elbows, and ecchymoses in various stages
of healing over the knees. Mental status examination shows a neutral affect. He says that he likes to run and climb
trees. Which of the following is the most likely explanation for these findings?
(A)
(B)
(C)
(D)
(E)

122.

Amyotrophic lateral sclerosis


Diabetes mellitus
History of gastrectomy
Meniere disease
Multiple sclerosis
Vertebrobasilar deficiency

Attention-deficit/hyperactivity disorder
Conduct disorder
Learning disorder
Seizure disorder
Age-appropriate behavior

A 47-year-old woman, gravida 2, para 2, comes to the physician after a screening at a health fair showed a serum
total cholesterol concentration of 280 mg/dL, HDL-cholesterol concentration of 78 mg/dL, and a triglyceride
concentration of 1420 mg/dL. She underwent the screening after eating dinner. She has a history of fibrocystic
breast disease. She takes no medications. Her father has a history of coronary artery disease. She is 173 cm (5 ft 8
in) tall and weighs 63 kg (139 lb); BMI is 21 kg/m2. Her temperature is 37C (98.6F), pulse is 80/min, respirations
are 14/min, and blood pressure is 110/70 mm Hg. Examination shows no abnormalities. Which of the following is
the most appropriate next step in management?
(A)
(B)
(C)
(D)
(E)

Therapeutic lifestyle diet


Fasting serum lipid studies
Atorvastatin therapy
Gemfibrozil therapy
Niacin therapy

49

123.

An 18-year-old man is brought to the emergency department 45 minutes after his car slid off an icy road into a
telephone pole at approximately 35 miles per hour. He was the restrained driver, and the air bag inflated.
Examination shows multiple contusions over the chest bilaterally; there is tenderness to palpation over the right
lower chest wall. The abdomen is flat, soft, and nontender. A complete blood count and serum concentrations of
electrolytes, urea nitrogen, and creatinine are within the reference range. Toxicology screening is negative. His urine
is pink; urinalysis shows 80 RBC/hpf but no WBCs. Which of the following is the most appropriate next step in
management?
(A)
(B)
(C)
(D)
(E)

124.

A 25-year-old woman comes to the physician because of a 2-month history of numbness in her right hand. During
this period, she has had tingling in the right ring and small fingers most of the time. She has no history of serious
illness and takes no medications. She is employed as a cashier and uses a computer at home. She played as a pitcher
in a softball league for 5 years until she stopped 2 years ago. Vital signs are within normal limits. Examination
shows full muscle strength. Palpation of the right elbow produces a jolt of severe pain in the right ring and small
fingers. Sensation to pinprick and light touch is decreased over the medial half of the right ring finger and the entire
small finger. The most likely cause of these findings is entrapment of which of the following on the right?
(A)
(B)
(C)
(D)
(E)

125.

CT scan of the abdomen and pelvis with contrast


Magnetic resonance arteriography of the renal arteries
Intravenous administration of antibiotics
Exploratory laparotomy
No further studies are indicated

Brachial plexus at the axilla


Median nerve at the wrist
Musculocutaneous nerve at the forearm
Radial nerve at the forearm
Ulnar nerve at the elbow

A previously healthy 17-year-old girl comes to the physician because of a 2-month history of exercise-induced
cough and nasal congestion. She plays field hockey and has noticed she coughs when running up and down the field.
The cough is nonproductive and resolves with rest. She has not had chest pain or palpitations. She takes no
medications and does not smoke. Her sister has asthma. The patient appears well. Her pulse is 68/min, respirations
are 16/min, and blood pressure is 100/75 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 99%.
Cardiopulmonary examination shows no abnormalities. An x-ray of the chest shows no abnormalities. Spirometry
shows an FEV1:FVC ratio of 90% and an FEV1 of 90% of predicted. Which of the following is the most likely
diagnosis?
(A)
(B)
(C)
(D)
(E)

Asthma
Chronic bronchitis
Gastroesophageal reflux disease
Postnasal drip syndrome
Variable endothoracic upper airway obstruction

50

The response options for the next 2 items are the same. Select one answer for each item in the set.
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(I)
(J)

Clostridium tetani
Cytomegalovirus
Escherichia coli
Group B streptococcus
Herpes simplex virus
Listeria monocytogenes
Parvovirus B19
Rubella virus
Toxoplasma gondii
Treponema pallidum

For each newborn with an infection, select the most likely pathogen.
126.

A 2500-g (5-lb 9-oz) full-term newborn has opacities obscuring the fundi and a continuous murmur heard over the
left hemithorax. He was born to a 21-year-old primigravid woman following an uncomplicated labor and delivery.
The mother received no prenatal care, and pregnancy was complicated by an erythematous rash during the first
trimester. She has had five sexual partners during the past year.

127.

A full-term newborn is brought to the emergency department at 5 days of age because of abnormal extremity
movements for 6 hours. The newborn was delivered at home to a 21-year-old primigravid woman who received no
prenatal care. The infant is alert, afebrile, hypertonic, and hyperreflexic. Complete blood count, serum electrolyte
concentrations, and cerebrospinal fluid analysis are within normal limits.

The response options for the next 2 items are the same. Select one answer for each item in the set.
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)

Factor VIII deficiency


Factor IX deficiency
Fibrinogen deficiency
Protein C deficiency
Protein S deficiency
Thrombocytopenia
Vitamin K deficiency
von Willebrand factor deficiency

For each patient with excessive bleeding, select the most likely cause.
128.

A 17-year-old girl comes to the physician 5 days after she was found to have a hemoglobin concentration of 9 g/dL
during a school blood drive. She has a history of frequent nosebleeds. Menarche began at the age of 15 years, and
her menses have occurred at regular 28-day intervals and last 9 to 10 days; she has heavy bleeding on all but the last
day. Her mother and older sister have similar symptoms. Physical and pelvic examinations show no abnormalities.
Today, her hemoglobin concentration is 9 g/dL, leukocyte count is 8000/mm 3, and platelet count is 300,000/mm3.

129.

A 5-year-old boy is brought to the physician because of a 1-week history of excessive bruising and bleeding from
minor cuts. He also has had a 2-week history of pain in his extremities. He appears pale. His temperature is 38.3C
(100.9F). Examination shows bleeding gums and scattered petechiae and purpura over the trunk and extremities.
There is generalized lymphadenopathy and splenomegaly.

51

The response options for the next 2 items are the same. Select one answer for each item in the set.
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(I)
(J)
(K)

Coronary artery thrombosis


Coronary artery vasospasm
Costochondritis
Dissecting aortic aneurysm
Esophageal spasm
Pericarditis
Pleuritis
Pneumonia
Pneumothorax
Postmyocardial infarction syndrome
Pulmonary infarction

For each patient with chest pain, select the most likely cause.
130.

A previously healthy 25-year-old woman comes to the physician because of substernal chest tightness and shortness
of breath for 2 hours. Twenty minutes before the onset of the pain, she had smoked crack cocaine. Her pulse is
110/min, and blood pressure is 170/100 mm Hg. Bilateral basilar crackles are heard. There is an S 4 gallop. A
nonradiating, grade 2/6, systolic ejection murmur is heard at the upper right sternal border.

131.

A previously healthy 57-year-old man comes to the physician because of shortness of breath for 5 days. At a recent
health fair, he was told that his blood pressure and cholesterol were high. He takes no medications. His pulse is
85/min, respirations are 16/min, and blood pressure is 200/110 mm Hg. The lungs are clear to auscultation.
Antihypertensive therapy with hydrochlorothiazide is initiated, and a follow-up visit is scheduled in 1 week. The
next day, he comes to the emergency department because of severe substernal chest pain radiating to the jaw. He has
diaphoresis and dyspnea. His temperature is 37C (98.6F), pulse is 110/min, respirations are 20/min, and blood
pressure is 175/100 mm Hg. Bilateral basilar crackles are heard. There is an S 4 gallop.

52

Answer Sheet for Step 2 CK Sample Questions


Block 1 (Questions 1-41)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

____
____
____
____
____
____
____
____
____
____

11.
12.
13.
14.
15.
16.
17.
18.
19.
20.

____
____
____
____
____
____
____
____
____
____

21.
22.
23.
24.
25.
26.
27.
28.
29.
30.

____
____
____
____
____
____
____
____
____
____

31.
32.
33.
34.
35.
36.
37.
38.
39.
40.

____
____
____
____
____
____
____
____
____
____

41.

____

82.
83.
84.
85.
86.

____
____
____
____
____

127.
128.
129.
130.
131.

____
____
____
____
____

Block 2 (Questions 42-86)


42.
43.
44.
45.
46.
47.
48.
49.
50.
51.

____
____
____
____
____
____
____
____
____
____

52.
53.
54.
55.
56.
57.
58.
59.
60.
61.

____
____
____
____
____
____
____
____
____
____

62.
63.
64.
65.
66.
67.
68.
69.
70.
71.

____
____
____
____
____
____
____
____
____
____

72.
73.
74.
75.
76.
77.
78.
79.
80.
81.

____
____
____
____
____
____
____
____
____
____

Block 3 (Questions 87-131)


87.
88.
89.
90.
91.
92.
93.
94.
95.
96.

____
____
____
____
____
____
____
____
____
____

97.
98.
99.
100.
101.
102.
103.
104.
105.
106.

____
____
____
____
____
____
____
____
____
____

107.
108.
109.
110.
111.
112.
113.
114.
115.
116.

____
____
____
____
____
____
____
____
____
____

117.
118.
119.
120.
121.
122.
123.
124.
125.
126.

53

____
____
____
____
____
____
____
____
____
____

Answer Key for Step 2 CK Sample Questions

Block 1 (Questions 1-41)


1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

F
D
C
A
A
G
F
D
A
D

11.
12.
13.
14.
15.
16.
17.
18.
19.
20.

B
A
B
A
A
C
F
A
B
B

21.
22.
23.
24.
25.
26.
27.
28.
29.
30.

A
E
B
B
A
C
B
E
B
C

31.
32.
33.
34.
35.
36.
37.
38.
39.
40.

D
E
D
D
A
G
D
D
H
F

41. C

Block 2 (Questions 42-86)


42.
43.
44.
45.
46.
47.
48.
49.
50.
51.

C
E
D
E
B
F
E
A
C
B

52.
53.
54.
55.
56.
57.
58.
59.
60.
61.

D
E
A
D
E
D
A
D
B
E

62.
63.
64.
65.
66.
67.
68.
69.
70.
71.

B
H
A
B
C
E
D
C
D
B

72.
73.
74.
75.
76.
77.
78.
79.
80.
81.

B
E
E
E
A
E
A
B
E
D

82.
83.
84.
85.
86.

B
B
E
B
G

127.
128.
129.
130.
131.

A
H
F
B
A

Block 3 (Questions 87-131)


87.
88.
89.
90.
91.
92.
93.
94.
95.
96.

E
B
D
B
D
C
B
D
B
E

97.
98.
99.
100.
101.
102.
103.
104.
105.
106.

A
C
A
A
D
E
F
C
A
A

107.
108.
109.
110.
111.
112.
113.
114.
115.
116.

C
A
D
C
D
B
J
D
A
B

117.
118.
119.
120.
121.
122.
123.
124.
125.
126.

54

C
A
D
C
A
B
A
E
A
H